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THE 



AMERICAN JOURNAL 



OF THE 



MEDICAL SCIENCES. 



EDITED BY 

ISAAC HAYS, M.D., 

SURGEON TO WILLS HOSPITAL, 

FELLOW OF THE PHILADELPHIA COLLEGE OF PHYSICIANS," MEMBER OF THE 

AMERICAN MEDICAL ASSOCIATION, - OF THE AMERICAN PHILOSOPHICAL SOCIETY; OF TH3K 

ACADEMY OF NATURAL SCIENCES OF PHILADELPHIA, 

&C. &C. &C. 



NEW SERIES 

VOL. XVIII. 




PHILADELPHIA: 
LEA & BLANCH* A RD. 

LONDON: 
WILEY & PUTNAM, AND JOHN MILLER. 



1849, 



69444 



Entered according to Act of Congress, in the year 1849, by 

LEA AND BLANCHARD, 

in the Clerk's Office of the District Court of the Eastern District of Pennsylvania. 




PHILADELPHIA : 
T. K. AND P. G. COLLINS, PRINTERS. 



v.18 
f\ed- 



TO READERS AND CORRESPONDENTS. 



Dr. Norris's Statistics of Ligature of the Femoral Artery, Dr. Mettauer's 
paper on Ligature of the Common Carotid, Dr. Atlee's Cases of Ovariotomy, 
and Dr. McSherry's Remarks on the Influence of Sea Life on Health, will appear 
in our next Number. 

The following works have been received: — 

Human Anatomy. By Jones Quain, M.D. Edited by Richard Quain, 
F. R. S., and William Sharpey, M. D., F. R. S., &c. &c. First American, from 
the fifth London edition. Edited by Joseph Leidy, M. D. Two vols., with 
over 500 illustrations. Philadelphia, Lea & Blanchard, 1849. (From the Pub- 
lishers.) 

Parturition, and the Principles and Practice of Obstetrics. By Tyler Smith, 
M. D. Philadelphia, Lea & Blanchard, 1849. (From the Publishers.) 

Practical Pharmacy: the Arrangements, Apparatus, and Manipulations, of 
the Pharmaceutical Shop and Laboratory. By Francis Mohr, Ph. D., Assessor 
Pharmacie of the Royal Prussian College of Medicine, Coblentz ; and Theo- 
philus Redwood, Prof. Chem. and Pharm. to the Pharmaceutical Society of 
Great Britain. Edited, with extensive additions, by Wm. Procter, Jr., Prof, of 
Pharm. in the Philada. Coll. of Pharmacy. Illustrated by 500 engravings on 
wood. Philadelphia, Lea & Blanchard, 1849. (From the Publishers.) 

Chemical Technology : or, Chemistry applied to the Arts and to Manufactures. 
By Dr. F. Knapp, Prof, at the University of Giessen. Translated and edited, 
with numerous notes and additions, by Dr. Edmund Ronalds and Dr. Thomas 
Richardson. First American edition, with notes and additions, by Prof. Wal- 
ter R. Johnson. Vol. II. Illustrated with 246 engravings on wood. Phila- 
delphia, Lea & Blanchard, 1849. (From the Publishers.) 

Elements of Electro-Biology, or the Voltaic Mechanism of Man ; or Electro- 
Pathology, especially of the Nervous System ; and of Electro-Therapeutics. By 
Alfred Smee, F.R.S. Illustrated with numerous engravings on wood. Lon- 
don, 1849. (From the Author.) 

Recherches sur la Structure des Organes de l'Homme et des Animaux les plus 
connus. Par C. F. Boucher, M. D., Amiens. Avec 104 figures. Paris, 1848. 
(From the Author, through Dr. Ross.) 

Treatise upon the Nature and Treatment of Morbid Sensibility of the Retina, 
or Weakness of Sight. Being the dissertation to which the Boylston Medical 
Prize for 1848 was awarded upon the following question: "What is the nature 
and best mode of treatment of that affection of the eyes commonly called mor- 
bid sensibility of the retina?" By John H. Dix, M. D., M.S.S. Boston, 1849. 
(From the Author.) 

A Dictionary of Dental Science. Biography, Bibliography, and Medical Ter- 
minology. By Chapin A. Harris, M. D., D.D.S., Prof, of the Princ. and Pract. 
of Dental Surgery in the Baltimore College, &c. &c. Philadelphia, Lindsay & 
Blakiston, 1849. (From the Publishers.) 

Epidemic Cholera ; its History, Causes, Pathology, and Treatment. By G, 
B. Coventry, M. D., Prof, of Obst. and Med. Jurisp. in the Med. Inst. Geneva 
Coll., &c. &c. Buffalo, Geo. H. Derby & Co., 1849. (From the Publishers.) 

Effects of Chloroform and of strong Chloric Ether as Narcotic Agents. By 
John C. Warren, M. D., &c. Boston, 1849. (Reprinted from Amer. Journ. 
Med. Sci., April 1849.) 

A Practical Compendium of Midwifery : being the course of lectures on mid- 
wifery, and on the diseases of women and infants, delivered at St. Bartholo- 
mew's Hospital, by the late Robert Gooch, M. D. Prepared for publication by 
George Skinner, M.R.C.S.L. Fourth American edition. Philadelphia, E. Bar- 
rington and Geo. D. Haswell, 1849. (From the Publishers.) 

Chemical Analysis, Qualitative and Quantitative. By Henry M. Noad, Lec- 
turer on Chemistry, &c. With numerous additions, by Campbell Morfit, 
Pract. and Analyt. Chemist, with illustrations. Philadelphia, Lindsay & Bla- 
kiston, 1849. (From the Publishers.) 



4 TO READERS AND CORRESPONDENTS. 

Anaesthesia : or the Employment of Chloroform and Ether in Surgery, Mid- 
wifery, &c. By J. Y. Simpson, M. D., F.R.S.E., Prof, of Midwifery in the Univ. 
of Edinburgh, &c. &c. Philadelphia, Lindsay and Blakiston, 1849. (From 
the Publishers.) 

The Maternal Management of Children, in Health and Disease. By Thomas 
Bull, M. D., M.R.C.P. From the third London edition. Philadelphia, Lind- 
say & Blakiston, 1849. (From the Publishers.) 

A Manual of Auscultation and Percussion, by M. Barth, Agrege of the Fa- 
culty of Medicine of Paris, &c. &c, and Henry Roger, Physician to the Bu- 
reau Central of the Parisian Hospitals, &c. &c. Translated, with additions, by 
Francis (j. Smith, M. D., Lect. on Phys. in the Philada. Association for Medi- 
cal Instruction, &c. Second edition. Philadelphia, Lindsay & Blakiston, 
1849. 

Summary of the Transactions of the College of Physicians of Philadelphia. 
From Feb. 6th, to April 3d, 1849, inclusive. 

The New Jersey Medical Reporter, and Transactions of the New Jersey 
Medical Society. Edited by Joseph Parrish, M. D. April, 1849. 

The Quarterly Journal of the Chemical Society of London. Edited for the 
Society, by Edmund Ronalds, Ph. D. April, 1849. 

Proceedings of the State Medical Convention, held in Macon, March, 1849, 
and Constitution of the Medical Society of the State of Georgia. Macon, 1849. 

Report of the Sub-Committee on Cleansing the City, (presented to the general 
committee June 5th, 1849,) relative to the best means of securing the health 
and cleanliness of the city. Philadelphia, 1849. (From the Councils.) 

Report No. 114. House of Representatives Minority Report. W. T. G-. Mor- 
ton. Washington, 1849. 

An Inaugural Address, delivered before the New York Academy of Medicine 
Feb. 7th, 1849. By Valentine Mott, M. D. To which is prefixed an address 
by Dr. J. W. Francis to the President elect. New York, 1849. 

A Report on Epidemic Cholera, read before the Medical Society of Frederick 
County, by Wm. Waters, M. D. Frederick, 1849. (From Dr. S. Tyler.) 

Address on the Progress and Dignity of the Medical Profession. Delivered 
before the Trustees, Faculty, Students, and Friends of the Starling Medical 
College, at its annual commencement, Feb. 17th, 1849. By B. T. Cushing, Esq. 
Published by request of the Trustees and Faculty. Columbus, 1849. 

Speeches of Defendants' Counsel, and the Charge of Judge Burnside, in the 
case of Hinchman vs. Richie et al. Reported by Oliver Dyer and Dennis F. 
Murphy. Philadelphia, 1849. 

Cholera: A Series of Letters communicated to " The Standard and Reformer." 
By Frank A. Ramsey, M. D., late Prof. Mat. Med. and Therap., in Memphis 
Med. College. Knoxville, 1849. 

The History of the Mild Yellow Fever which prevailed in the city of Natchez 
in 1848, with Observations respecting its Character and Natural Mode of Cure ; 
to which are appended, from various authors, descriptions and notices of that dis- 
ease ; of dengue, and of inflammation of the stomach and bowels. By C. W. 
Stone, M.D., of Natchez. Vidalia, 1849. 

Treatise on Epidemic Cholera : being Lectures delivered under the authority 
of the Faculty of Medicine of Paris. By Ambroise Tardieu, M. D. Trans- 
lated from the French by S. L. Bigelow, M. D. With an Appendix by a Fellow 
of the Massachusetts Medical Society. Boston, Ticknor, Reed & Fields, 1849. 

A Theoretical and Practical Treatise on Human Parturition. By H. Miller, 
M. D., Prof, of Obs. &c. in Med. Dep. University of Louisville. Louisville, 
1849. (From the Author.) 

Catalogue and Circular of the Medical Department of the University of the 
State of Missouri. Session 1848-49. St. Louis, 1849. 

Catalogue of the Class in the Philada. College of Medicine, for the session 
1848-49, and the annual announcement for the session 1849. Philadelphia, 1849. 

Catalogue of the Officers and Students of Bowdoin College, and the Medical 
School of Maine. Spring Term, 1849. 

Catalogue of the Medical Department of Transylvania University, with a list 



TO READERS AND CORRESPONDENTS. 

of the Graduating Class, and also the announcement for the Session of 1849- 
1850. Lexington, 1849. 

Valedictory Address to the Medical Class of the Transylvania University. 
By E. L. Dudley, M.D., Prof. Gen. and Path. Anat. and Phys. Lexington, 
1849. (From the Author.) 

Valedictory Address to the Graduating Class of the Medical Department of 
Pennsylvania College at the annual commencement, March 7, 1849. By Henry 
S. Patterson, M. D., Prof. Mat. Med. and Therap. Philadelphia, 1849. (From 
the Author.) 

Address to the Graduating Class of Rush Medical College. Session 1848- 
49. By Daniel Brainard, M. D., President of the College. Chicago, 1849. 
(From the Author.) 

Annual Report of the Trustees of the State Library of the State of New York, 
made to the Legislature Jan. 15, 1849. Albany, 1849. (From T. R. Beck, 
M.D.) 

Fracture Tables, showing the results of treatment in 136 cases. By Dr. F. 
H. Hamilton. Buffalo, 1849. (From the Author.) 

Valedictory Address to the Graduating Class of Geneva Medical College at 
the public commencement, Jan. 23d, 1849. By Chas. A. Lee, M. D., Prof. Gen. 
Path, and Mat. Med. Buffalo, 1849. (From the Author.) 

Service-Pipes for Water : an investigation made at the suggestion of the Board 
of Consulting Physicians, of Boston, by E. N. Horsford Rumford, Prof, in the 
Univ. of Cambridge. From the Proceedings of the Academy of Arts and 
Sciences. Cambridge, 1849. (From the Author.) 

The Philosophy of Medicine. An Address delivered before the Graduates of 
the Medical College of Georgia, on the 20th of March, 1849. By John Le 
Conte, M. D., Prof. Nat. Philos. and Chem. in Franklin Coll. Univ. of Georgia. 
Augusta, 1849. 

Catalogue of the Plants, Native and Naturalized, collected in the Vicinity of 
Cincinnati (during the years 1834-44). By Thomas G. Lea. Philadelphia, 

Remarks on the Construction of the Obstetrical Forceps, with a description 
of an instrument employed by Jas. P. White, M. D., Prof, of Obstetrics in Med. 
Dep. of Univ. of Buffalo. From May number of Buffalo Journal. 

The following Journals have been received in exchange : — 

Revue Medico-Chirurgicale de Paris. Sous la direction de M. Malgaigne, 
April, May, 1849. 

Gazette Medicale de Paris. Oct., Nov., Dec, 1848, (except No. 47,) Jan. and 
Feb. 1849. 

Revue Medicale Franchise et Etrangere. Par J. B. Cayol. Sept., Oct., Nov., 
Dec, 1848. 

Journal de Medecine et de Chirurgie pratiques. Par Lucas-Championniere. 
Oct., Nov., Dec, 1848. 

Annales de Therapeutique Medicale et Chirurgicale et de Toxicologie. Par 
M. le Docteur Rognetta. Sept., Oct., Nov., Dec, 1848, Jan. 1849. 

Journal des Connaissances Medico-Chirurgicales. Par Le Dr. A. Martin- 
Lauzer. Nov., Dec, 1848, Jan., Feb., March, 1849. 

Journal des Connaissances Medicales pratiques et de Pharmacologic Oct., 
Nov., Dec, 1848, Jan., Feb., 1849. 

Annales Medico-Psychologiques, Journal de TAnatomie, de la Physiologie, et 
de la Pathologie du Systeme Nerveux. Par MM. les Docteurs Baillarger, 
Cerise, et Longet. July, Sept., Nov., 1848. 

Journal de Pharmacie et de Chimie, par MM. Boullay, J. P. Boudet, Bussy, 
Soubeiran, Henry, F. Boudet, Cap, Boutron-Charlard, Fremy, et Guibourt. 
Suivi d'une Compte Rendu des Traveaux de Chimie, par le Charles Gerhardt. 
Oct., Nov., Dec, 1848._ 

La Lancette Francaise, Gazette des Hopitaux, civils etmilitaires. Oct., Nov. 3 
Dec, 1848, except No. 143. 

The Edinburgh Medical and Surgical Journal, April, 1849. 

The London Medical Gazette. March, April, May, 1849. 

1* 



6 TO READERS AND CORRESPONDENTS. 

Provincial Medical and Surgical Journal. Edited by Robert J. N. Streeten, 
M. D. Foreign editor, Wm. H. Ranking, M. D. March, April, May, 1849. 

Monthly Journal and Retrospect of the Medical Sciences. Edited by Geo. 
E. Day, F.R.C.L., Alex. Fleming, M. D., and W. T. Gairdner, M. D. April, 
May, June, 1849. 

Dublin Medical Press. March, April, May, 1849. 

London Journal of Medicine, a monthly record of the Medical Sciences. 
March, April, May, 1849. 

The British and Foreign Medico-Chirurgical Review. April, 1849. 

The Dublin Quarterly Journal of Medical Science. May, 1849. 

The American Journal of Pharmacy. Published by authority of the Phila- 
delphia College of Pharmacy. Edited by Joseph Carson, M. D., and Wm. 
Procter, Jr., &c. April, 1849. 

The Western Journal of Medicine and Surgery. Edited by L. P. Yandell, 
M. D. April, May, June, 1849. 

Buffalo Medical Journal and Monthly Review. Edited by Austin Flint, 
M. D. April, May, June, 1849. 

St. Louis Medical and Surgical Journal. Edited by Drs. Linton, Moore, 
McPheeters, and McDowell. March, April, 1849. 

The New Orleans Medical and Surgical Journal. Edited by A. Hester, 
M. D., May, 1849. 

The Annalist ; A Record of Practical Medicine in the City of New York. 
Edited by N. S. Davis, M. D. April, May, June, 1849. 

The Charleston Medical Journal and Review. Edited by Dr. P. C. Gail- 
lard and H. W. De Saussure. May, 1849. 

The New York Journal of Medicine and the Collateral Sciences. May, 1849. 

The American Journal and Library of Dental Science. Edited by Dr. A. 
Harris, A. Westcott, and W. H. Dwinnell. April, 1849. 

The Medical Examiner and Record of Medical Science. Edited by Francis 
G. Smith, M. D., and David H. Tucker, M. D. April, May, June, 1849. 

Southern Medical and Surgical Journal. Edited by Paul F. Eve, M. D. 
April, May, June, 1849. 

The Ohio Medical and Surgical Journal. Edited by John Butterfield, 
M. D. March, May, 1849. 

The Boston Medical and Surgical Journal. April, May, June, 1849. 

The American Journal of Insanity. Edited by the officers of the New York 
State Lunatic Asylum, Utica. April 1849. 

The Northwestern Medical and Surgical Journal. Edited by Drs. Herrick 
and Evans. Chicago, 1849. March, May, 1849. 

The Western Lancet and Hospital Reporter. Edited by L. M. Lawson, M. D., 
and J. P. Harrison, M. D. April, May, June, 1849. 

The American Journal of Science and the Arts. Edited by Prof. B. Silli- 
man, and B. Silliman, Jr., and James D. Dana. May, 1849. 

Communications intended for publication, and Books for Review, should be sent, free, 
of expense, directed to Isaac Hats, M. D., Editor of the American Journal of the Medical 
Sciences, care of Messrs. Lea & Blanchard, Philadelphia. Parcels directed as above and 
sent (carriage paid) under cover, to John Miller, Henrietta Street, Covent Garden, Lon- 
don; or to Wiley & Putnam, New York; or W. D. Ticknor, Boston; or M. Hector Bos- 
sange, Lib. quai Voltaire, No. 11, Paris, will reach us safely and without delay. We 
particularly request the attention of our foreign correspondents to the above, as we are 
often subjected to unnecessary expense for postage and carriage. 

All remittances of money, and letters on the business of the Journal, should be addressed 
exclusively to the publishers, Messrs. Lea & Blanchard. 

<Xj* The advertisement-sheet belongs to the business department of the Journal, and 
all communications for it should be made to the publishers. 



CONTENTS 



OF THE 



AMERICAN JOURNAL 



OF THE 



MEDICAL SCIENCES. 

NO. XXXV. NEW SERIES. 
JULY, 1849. 



ORIGINAL COMMUNICATIONS. 
MEMOIRS AND CASES. 

ART. PAGE 

I. A brief Account of the Origin, Progress, Symptoms, Mortality, and 
Treatment of Pestilential Cholera, as it occurred in the Mississippi Val- 
ley, and especially in the city of Memphis. By Lewis Shanks, M. D., of 
Memphis, Tenn. - - - - - - - -13 

II. Extracts from the Records of the Boston Society for Medical Improve- 
ment. By Samuel Parkman, M. D., Secretary. - - - - 35 

III. Lithotrity and Lithotomy, with the use of Ether in those operations. 

By J. Mason Warren, M. 1). - - - - - -47 

IV. On Nitrate of Silver in Jaundice. By J. F. Peebles, M. D., of Peters- 
burgh, Va. - - - - - - - - -59 

V. Notes of Hospital Cases. By Henry Hartshorne, M. D., of Philadel- 
phia. - - - - - - - - -63 

VI. On the use of the Oxide of Silver in certain forms of Menorrhagia, with 
Cases and Remarks. By J. J. Thweatt, M. D., Petersburg, Va. - 69 

VII. Congenital Phimosis. By M. G. Delaney, M. D., Surgeon U. S. Navy. 72 

VIII. Traumatic Tetanus treated with Chloroform. Recovery. — Read be- 
fore the "Boston Society for Observations in Medicine and the Collateral 
Sciences." By Edward II. Clarke, M. D. 75 

IX. On the Influence upon Health of the Introduction of Tea and Coffee 
in large proportion into the Dietary of Children and the Labouring 
Classes. By Samuel Jackson, M. D., Professor of the Institutes of Medi- 
cine in the University of Pennsylvania. - - - - - 79 

X. Surgical Cases. By James D. Trask, M. D., Whiteplains, Westchester 
County, New York. - - - - - - - 86 

XL On the Action of Poisons. By James Blake, M. D., F. R. C. S. E., Pro- 
fessor of Anatomy at the St. Louis University. - - - - 97 

XII. On Contagion. By Samuel Henry Dickson, M. D., Prof, of Theory 
and Practice of Medicine in the University of the City of New York. - 107 

XIII. Contributions to Pathological Anatomy. By Jno. Neill, M. D., De- 
monstrator of Anatomy in the University of Pennsylvania. [With five 
wood cuts.] --------- 118 



8 CONTENTS. 

ART. PAGE 

XIV. Case of Caesarian Operation. By A. B. Shipman, M. D., Professor 

of Surgery in Indiana Medical College. ----- 122 

XV. Complete Inversion and Expulsion of the Uterus. By Thomas H. 
Yardley, M. D., Consulting Physician to the Lying-in Department of the 
Northern Dispensary of Philadelphia, &c. - - 126 

XVI. Two Cases of Spontaneous Luxation of the Hip Joint. By Henry 

A. Ramsay, M. D., Raysville, Ga. - - - - - 127 

REVIEWS. 

XVII. Practical Treatise on Ventilation. By Morrill Wyman. 12mo. pp. 
404. Boston: Jas. Munroe & Co., 1846. 

Report of a Committee of the American Academy of Arts and Sciences on 
Ventilation and Chimney-tops. 8vo. pp. 28. Cambridge : Metcalf & 
Co., 1848. 

Practical Methods of Ventilating Buildings. By Luther V. Bell, M. D., 
LL. D., Honorary Member of the New York State Medical Society, etc., 
Physician and Superintendent of the McLean Asylum for the Insane — 
a department of the Massachusetts General Hospital. 8vo. pp. 131. Bos- 
ton : Damrell & Moore, 1848. 

Ventilation of School-Houses of the City of Boston. Report of Committee. 
8vo. pp. 43. Boston: J. H. Eastburn, 1848. 

Ventilation Illustrated: a Tract for the Schools of Rich and Poor. 12mo. 
pp. 36; second edition. London: John Churchill, 1848. 

Uses and Abuses of Air : showing its Influence in Sustaining Life and Pro- 
ducing Disease ; with Remarks on the Ventilation of Houses. Parts I. 
and II. ; 12mo. pp. 144. New York: J. S. Redfield, 1848. - - 129 

XVIII. On the Influenza, or Epidemic Catarrhal Fever of 1847-8. By 
Thomas Bevill Peacock, M. D., Physician to the Royal Free Hospital, 
&c. London, 1848 : pp. 182. ' 148 

BIBLIOGRAPHICAL NOTICES. 

XIX. Practical Pharmacy. The Arrangements, Apparatus, and Manipu- 
lations of the Pharmaceutical Shop and Laboratory. By Francis Mohr, 
Ph. D., and Theophilus Redwood: edited, with extensive additions, by 
Win. Procter, Jr. Illustrated by 500 engravings on wood. Philadel- 
phia: Lea and Blanchard, 1849. ------ 155 

XX. Human Anatomy. By Jonas Quain, M. D. Edited by Richard 
Quain, M. D., and William Sharpey, M. D., F.R.S., Professors of Anato- 
my and Physiology, in University College, London. First American, 
from the fifth London edition. Edited by Joseph Leidy, M. D. In two 
volumes, with over 500 illustrations. Philadelphia : Lea & Blanchard, 
1849. 157 

XXI. Seventh Annual Report to the Legislature, relating to the Registry 
and Returns of Births, Marriages, and Deaths, in Massachusetts, for the 
year ending April 30th, 1848. By Wm. B. Calhoun, Secretary of the 
Commonwealth. 8vo. : pp. 56. 

Report of the Secretary of State, of the Number of Births, Marriages, and 
Deaths [in the State of New York] for the year 1847. 8vo. : pp. 56. - 163 

XXII. On the Cryptogamous Origin of Malarious and Epidemic Fevers. 
By J. K. Mitchell, A. M., M. D., Professor of Practical Medicine in the 
Jefferson Medical College of Philadelphia. Philadelphia, 1849: 8vo. 

pp. 137. Lea & Blanchard. - - 168 

XXIII. A Practical Treatise on the Domestic Management and Most Im- 
portant Diseases of Advanced Life ; with an Appendix, containing a 
Series of Cases illustrative of a new and successful mode of treating 
Lumbago and other forms of Chronic Rheumatism, Sciatica and other 
Neuralgic Affections, and certain forms of Paralysis. By George Day, 



CONTENTS. 



AET. PAGE 

M. D., Fellow of the Royal College of Physicians, and Physician to the 
Western General Dispensary. 8vo. pp. 226. Philadelphia : Lea & 
Blanchard, 1849. - - - - - - -175 

XXIV. Parturition, and the Principles and Practice of Obstetrics. By 
W. Tyler Smith, M. D., Lond. ; Lecturer on Obstetrics in the Hunt- 
erian School of Medicine. 12mo. pp. 395. Lea & Blanchard: 1849. - 179 

XXV. Reports, for 1848, of Institutions for the Insane in the United States: 
1st. Of the McLean Asylum for the Insane, Somerville, Massachusetts. 
2d. The State Lunatic Hospital, Worcester, Massachusetts. 

3d. The Boston Lunatic Hospital, South Boston, Massachusetts. 

4th. The Butler Hospital for the Insane, Providence, Rhode Island. 

5th. The State Lunatic Asylum, Utica, New York. 

6th. The State Lunatic Asylum, Trenton, New Jersey. 

7th. The Pennsylvania Hospital for the Insane, near Philadelphia, Pa. 

8th. The Western Asylum, Staunton, Virginia. 

9th. The Hospital for the Insane, Indianapolis, Indiana. - - - 186 

XXVI. An Account of some of the most important Diseases of Women. 
By Robert Gooch, M. D., with illustrations. Second edition. Philadel- 
phia: Ed. Barrington and Geo. D. Haswell, 1849. 8vo. pp. 322. 

A Practical Compendium of Midwifery ; being the Course of Lectures on 
Midwifery, and on the Diseases of Women and Infants, delivered at St. 
Bartholomew's Hospital, by the late Robert Gooch, M. D. Prepared for 
publication by George Skinner, M. R. C. S. Fourth American edition. 
Philadelphia: Ed. Barrington & Geo. D. Haswell, 1849. 8vo. pp. 339. 196 

XXVII. Anaesthesia, or the Employment of Chloroform and Ether in Sur- 
gery, Midwifery, &c. By J. Y. Simpson, M. D., F. R. S. E. Professor of 
Midwifery in the University of Edinburgh, &c. Philadelphia : Lindsay 

& Blakiston, 1849. 8vo. pp. 248. 196 



QUARTERLY SUMMARY 

OF THE 

IMPROVEMENTS AND DISCOVERIES IN THE 
MEDICAL SCIENCES. 



FOREIGN INTELLIGENCE. 

Anatomy and Physiology. 



PAGE 



1. On the Development and Func- 
tions of the Spermatozoa. By 
Drs. Wagner and Leuckardt. - 197 

2. Hassal's Parasite. - 197 

3. Structure of the Papillae of the 



PAGE 

Tongue. By Mr. Hassall. - 198 
4. On the Minute Structure and 
Mode of Contraction of Volun- 
tary Muscular Fibre. By W. 
Murray, Dobie, Esq. - - 196 



Organic Chemistry. 



5. Chemical Pathology of Diar- 
rhoea. By Oesterlin. - - 199 

6. On the Source of Sugar in the 



Animal Economy. By Dr. Ber- 
nard. 201 



10 



CONTENTS. 



Materia Medica and Pharmacy. 



page 

7. On Sugar as an Antiphrodisiac. 

By M. Provencal. - - - 203 

8. Physiological Action of Nitrate 

of Potassa. By F. Loffler. - 204 

9. Experiments on Senna and Ar- 
gol Leaves. By Heberlein. - 205 



PAGE 

10. Sulphate of Amorphous Qui- 
nine. By Mr. Bullock. - - 205 

11. On the Employment of Nitrate 
of Silver as a Vesicant. By M. 
Delvaux. 206 

12. The Mechanical Leech of MM. 
Alexandre & Co. of Paris. - 207 



Medical Pathology and Therapeutics, and Practical Medicine. 



13. On the Analogy and Differ- 
ences between Tubercle and 
Scrofula. By M. A. Legrand. - 

14. On Spinal Meningitis. By M. 
Piorry. 

15. Causes and Morbid Anatomy 
of Mental Diseases. By Dr. 
John Webster. - 

16. On Polydipsia. By M. Vigla. 

17. Effects of Cauterization in In- 
oculation with Virulent Poison- 
ous Agents. By M. Parchappe. 

18. Period required for the Ab- 



207 
208 



209 
210 



211 



sorption of Virus. By M. Re- 
nault. - - - - - 211 

19. On the Simultaneous Develop- 
ment of Variola and Vaccinia. 

By MM. Herard and Bousquet. 212 

20. On the Influence of Physical 
Agents in Variola. By M. Ser- 
res. - - - - - - 213 

21. Nux Vomica in Intestinal Ob- 
structions. By Dr. Ossieur. - 213 

22. Extractum Cotyledonis Umbi- 
lici in Epilepsy. By Dr. Joseph 
Bullar. 214 



Surgical Pathology and Therapeutics, and Practical Surgery. 



23. Pathology and Treatment of 
the Deafness attendant upon Old 
Age. By Mr. Joseph Toynbee. 215 

24. Traumatic Pleuro-Pneumonia. 

By M. Malgaigne. - - - 215 

25. On the Utility and Necessity 
of performing Paracentesis Tho- 
racis in certain cases of Pneu- 
mothorax. By Hamilton Roe, 

M. D. .-.-- 216 

26. Use of Nitrate of Silver for 
White Swellings, Hydrarthrosis, 
and Venereal Bubo. By M. De- 
caisne. 217 

27. On Valvular Obstructions as a 
Cause of Retention of Urine. By 

M. Mercier. - - - - 218 
23. On the Evils attending Ex- 
cision of the Tonsils. By Mr. 
Harvey. 219 

29. Arterial Compression as an 
Antiphlogistic. By Dr. Henroz 

de Marche. - - - - 219 

30. Treatment of Gonorrhoea by 



Vinum Colchici. By Dr. Fici- 
mus. ------ 220 

31. Case of Exfoliation of the An- 
terior Arch of the Atlas. By 
Robert Wade, Esq. - - - 220 

32. New Variety of Luxation of 
the Humerus. By M. Malgaigne. 221 

33. Staphyloraphy. By M. Gerdy. 221 

34. Ligature of the External Iliac 
Artery. By T. W. Nunn, Esq. 222 

35. Femoral Aneurism. By Mr. 
Tufnell. 222 

36. Popliteal Aneurism communi- 
cating with the Knee Joint. 
Amputation of the Thigh. By 
Mr. Adams. - - - - 226 

37. Popliteal Aneurism cured by 
Compression. By Mr. Tufnell. 228 

38. Remarks on the Objections 
which have been made against 
the Use of Pressure for the Cure 

of Aneurism. By Mr. Tufnell. 232 

39. Cases of Aneurism cured by 
Compression. By Dr. Edward 
Hutton. - - - - - 235 



Ophthalmology. 



40. On Inflammation of the Eye 
from Injury. By Dr. Jacob. - 236 

41. Ocular Apoplexy. By M. Mal- 
gaigne. 241 



42. Case of Traumatic Lesion of 
the Globe of the Eye. By Dr. 
Rivaud Landreaux. - 242 



CONTENTS. 



11 



Midwifery. 



page 

43. Iodine in Congestion and Ero- 
sion of the Cervix Uteri. By 
Dr. Churchill. - - - -243 

44. Tincture of Indian Hemp in 
Sanguineous Uterine Discharges. 

By Dr. Churchill. - - - 244 

45. Absence of Urea in the Liquor 
Amnii and Foetal Urine. By 
Dr. A. H. McClintock. - - 245 

46. Urethritis in the Female. By 
Dr. McClintock. - - - 246 

47. Puerperal Tetanus. By Dr. 
Pirre-Aubinais. - ' - 246 

48. Expulsion of a Bag of Waters 
before the Bupture of the Mem- 
branes. By Dr. Alexander 
Wood. 247 

49. Twins born at an interval of 
twenty-one days. - 247 



PAGE 

50. Case in which the Liquor Am- 
nii and the Meconium were both 
bloody. By Dr. Moir. - - 247 

51. On Prolapsus Uteri. By Pro- 
fessor Hohl. - 248 

52. Case of Hydrometria occurring 
in an Unimpregnated Uterus. 

By Dr. Grandidier. - - - 249 

53. Prolapsus of the Funis during 
Labour. By Dr. Hoffman. - 249 

54. Spontaneous Rupture of the 
Uterus — Recovery. By James 
Church, Esq. - 250 

55. Subacute Inflammation of the 
Ovaries and of the Fallopian 
Tubes as one of the Causes of 
Sterility. By Dr. Tilt. - - 250 

56. Cases of Sudden Death after 
Delivery. By Dr. McCowan. -251 



Cholera. 



57. Cholera. - 

58. Pathological Appearances in 
Cholera. By M. Virchow. 

59. Hypertrophy of Peyer's Glands 
in Cholera. - 

60. On the Pathological Condition 
of the Blood in Cholera. By A. 
B. Garrod,M.D. 

61. Analyses of the Blood in Chole- 
ra. By Dr. William Robertson. 

62. On the Liquids ejected in 
Cholera. By M. Mialhe. 



252 

252 
252 

253 

256 

257 



63. Pathology and Therapeutics of 
Cholera. By Dr. Garrod. - 258 

64. Cholera, 'By Mr. Streeter. - 259 

65. Effect of Remedies in Cholera. 261 

66. Treatment of Asiatic Cholera 
by Internal and External Means. 

By M. Blatin. - - - - 261 

67. Treatment of Cholera in six of 
the Parisian Hospitals. - - 262. 

68. Results of the various kinds of 
Treatment of Cholera adopted in 
Russia. By Dr. Mackenzie. 



272 



Anesthetic Agents. 



69. Death from Chloroform — 
Means to be employed to pre- 
vent a fatal effect from an over- 



dose. By Dr. Snow. 
70. Chloroform. By Dr. 
Snow. ... 



- 274 
John 

- 278 



Medical Jurisprudence and Toxicology. 



71. Poisoning by Sulphate of Zinc. 
By Professor Platner and Pig- 
nacca. 

72. Accidental Poisoning by Tinc- 
ture of Muriate of Iron. By Sir 



279 



James Murray. - - - 280 

73. Effects of the use of Arsenic 
in Agriculture. Poisoned Game. 
By Dr.. Fuller. - - - -281 



AMERICAN INTELLIGENCE. 

Original Communications. 



Abstract of a Paper on " The Mi- 
croscopical Appearances pre- 
sented in the Intestinal Dis- 
charges and Muscular Fibres of 



a patient who died of Epidemic 
Cholera." By Waldo (I.) Bur- 
nett. - 28S; 

Fourth Meeting of " The Associ- 



12 



CONTENTS. 



PAGE 

ation of Medical Superintendents 
of American Institutions for the 
Insane," at Utica, N. Y. - - 284 
Condyloid Process of the Occiput. 289 



PAGE 

Cholera. By N. Ward, M. D. - 289 
Nursing Sore Mouth. By J. Yale 

Ware. 290 

Aphtha. By J. Yale Ware. - 290 



Domestic Summary. 



Photophobia, resulting from ex- 
alted sensibility of the sensitive 
branch of the fifth pair going to 
the eye from irritation of the 
sensitive branch of the same 
nerve going to the teeth. By Dr. 
I. Hays. 

Deaths from the Inhalation of Sul- 
phuric Ether. By Dr. Paul F. 
Eve. 



291 



293 



Lupulin as an Anaphrodisiac. By 

Dr. Page, 

New Method of Expelling Foreign 

Bodies from the Larynx. By 

Dr. Charles Hansford. 
American Medical Association. - 
Cholera. - 
List of Graduates of the University 

of Pennsylvania. - 



293 



294 
294 
294 

296 



THE 

AMERICAN JOURNAL 
OF THE MEDICAL SCIENCES 

FOR JULY 1849. 



Art. I. — A brief Account of the Origin, Progress, Symptoms, Mortality, and 
Treatment of Pestilential Oholera, as it occurred in the Mississippi Valley, 
and especially in the city of Memphis. By Lewis Shanks, M. D., of Mem- 
phis, Tenn. 

The uncertainty which still exists as to the origin and mode of propagation 
of pestilential cholera, its extensive prevalence, and the enormous fatality 
which has everywhere attended its progress, invest all the facts connected 
with its history with deep interest ; for it is only by an accumulation of facts, 
and by their comparison, that we can hope to arrive at a knowledge of its 
causes and nature, and of the best means of staying its ravages. With the 
view of contributing our mite to this great work, we shall in the present 
article give a brief account of the disease as it occurred in Memphis, and 
generally in the Mississippi Valley. Our remarks upon it will be especially 
confined to an account, — 

1st. Of the general state of the weather before and during its prevalence. ; 

2c?. Of its commencement in Memphis, and the sanatory measures adopted. 

3cZ. Of the time and manner of its invasion of New Orleans, its extension 
along the principal rivers, the time and manner of its commencement and 
prevalence at Memphis, and the facts in reference to its cause and extension. 

4:th. Of the symptoms at the commencement and during its prevalence, as 
modified by the weather, &c. ; the post-mortem appearances, and the mortality. 

5th. Of the treatment. 

1st. State of the weather previous to the occurrence of cholera in Memphis. — 
In the absence of any regular and daily register of the thermometrical and 
hygrometrical changes, the general and striking peculiarities only can be given. 

About the 20th of last October the rainy season commenced here, and from 
that time until the 29th of December, with the exception of occasionally two 
or three fair days, it continued to be cloudy, and to rain frequently in very 
No. XXXV.— July ; 1849. 2 



14 Shanks on Pestilential Cholera. [July 

heavy and protracted showers; so that the streams in the country were 
generally unusually high, and the earth was kept saturated with water. 
During this long continuance of rain the temperature of the atmosphere was 
uncommonly warm for the season, and this was particularly so during the lat- 
ter part of December, up to the time that cases of cholera became sufficiently 
numerous to induce the Board of Health to announce its existence here, to a 
limited extent, as an epidemic, especially among the flatboat population along 
the landing. 

In connection with this account of the weather, it is proper to state, that 
about the middle of December, influenza, within a few days, affected a very 
large proportion of the population of Memphis, and extended rapidly over 
the country. Generally, the disease was mild. The catarrhal symptoms were 
preceded and accompanied by slight chilliness, aching in the head, back, and 
limbs ; but in some cases more decidedly inflammatory symptoms were de- 
veloped ; evinced by rigors, with fever, pneumonia, pleuritis or bronchitis, 
thirst, white fur upon the tongue, &c. It was fatal only in a few cases of 
delicate persons. 

On the 29th of December the weather cleared, and there was no rain until 
the 12th of January. This spell of dry weather was sufficiently cold to freeze 
the ground, and it continued, except a sleet on the night of the 8th of Janu- 
ary, for fourteen days. We call attention particularly to this, on account of the 
influence which it seemed to exert over both the increase and the symptoms 
of the disease, as will be more particularly noticed hereafter. 

2d. Its commencement in Memphis, and the sanatory measures adapted. — 
On the 20th of December, the steamboat Convoy, which runs in the Mem- 
phis and New Orleans trade, arrived here in four days' passage from New 
Orleans, with two or three cases among the hands on board, which were pro- 
nounced cholera by Dr. Ashbel Smith and other physicians who saw them. 
Two of these cases proved fatal. Several days previously to the arrival of the 
Convoy, other boats going up the river from New Orleans had reported cases 
and deaths on their passage, especially among the firemen and deck passengers. 

This certain evidence of the existence of cholera, in New Orleans, created 
some alarm here, and preparatory to its expected visitation of Memphis, the 
Board of Health urged the importance of immediately cleaning the streets, 
alleys, back yards, &c. ; and draining and filling up all low places, upon which 
any standing water remained, which was carried into effect by the city council. 

Means were also adopted to enlighten the public as to the best prophylactic 
means to be adopted, and as to the course they should follow in case of an 
attack. 

3d. Time and manner of the invasion of the disease. — Some facts as to the 
time at which cholera commenced in New Orleans, its progress there, &c, are 
interesting, for the purpose of showing the length of time required, after the 
first well-marked case, to develop the pestilence there, and to so infect per- 
sons on the boats as to transport the disease here. 



1849.] Shanks on Pestilential Cholera. 15 

These facts are furnished in an authoritative form, by Dr. Fenner, of New 
Orleans. (See the preceding number of this Journal, p. 541, et seq.) 

Dr. Fenner states, that the ship Swanton, from Havre, arrived at New 
Orleans on the 11th of December, and landed at the public wharf in the 
second Municipality. On the morning of the 12th, a woman of the Swanton 
was carried to the Charity Hospital, in a complete state of collapse. She was 
reported to have been attacked the night before with violent purging, vomit- 
ing, and cramps. On the 13th, a man, who was a passenger on the same 
vessel, was taken to the hospital in a collapsed state. The same day, the 
books show, that three other cases of cholera were received into the hospital, 
from different parts of the city. These five cases all terminated fatally. From 
the 13th, the daily number of admissions rapidly increased. On the 22d, in 
the hospital, 22 deaths occurred, and in private practice 23. The Board of 
Health reported on the 23d, that 45 deaths had occurred the previous day, of 
cholera; and that it was prevailing as an epidemic. By the 28th it had 
reached its climax j the largest number of deaths, 92, occurred on that day. 
On the 6th of January, only 38 deaths occurred, and the Board of Health 
announced the cessation of the epidemic. From its commencement to the 
20th of January, Dr. Fenner estimates the number of deaths in New Orleans 
at 1400. 

I have already stated that on the 20th of December, the steamboat Con- 
voy arrived at the Memphis wharf, with cases of cholera • and that several days 
previously to her arrival other boats, passing up the river, reported cases and 
deaths on their trip up to this point. Allowing four days for the trip up from 
New Orleans to Memphis, and that cases and deaths had occurred on boats 
passing this point on the 18th, the boats must have been infected, or the per- 
sons sickening and dying must have received the poison in New Orleans, on 
the 14th, two days after the first cases occurred. 

Previous to the 22d of December, I had not seen among our citizens, any 
striking tendency to bowel affections, more than usual in such damp, rainy 
weather. On that clay, at 2 P. M., I was called to see a boy 16 years old, who 
had been employed in huckstering fruit, &c, about town, and was in the habit of 
attending at the wharf, when boats landed, to sell to the passengers. He had 
been attending the landing, and was at the Convoy the day before, but did 
not go on board. 

When I saw him, he was in a state of complete and hopeless collapse, — 
blue, cold, pulseless, shrunk tongue, and breath cold; eyes sunk and injected, 
and his voice much altered. He was attacked the night before, about ten 
o'clock, with purging, vomiting, and towards morning cramps ; but had gone 
down stairs, into the back yard to the privy, until two hours before I saw 
him. A short time before this, he had discharged from his bowels about 
three-fourths of a pint of inodourous fluid resembling thin corn-meal gruel. 
About two o'clock that night he died. He had been labouring under a slight 
diarrhoea for several days before the attack. 



16 Shanks on Pestilential Cholera. [July 

Although nearly every boat, passing up at that time and afterwards, re- 
ported cases and deaths, no other case occurred here among the citizens until 
the 26th. 

A man and a woman about 41 years of age, residing one hundred and fifty 
yards distant from each other, and a quarter of a mile from the steamboat 
landing, were attacked on flatboats : both were temperate persons, and com- 
fortably situated on their boats. They were deceived by the insidious pro- 
gress of the disease, and, for the want of timely and efficient treatment, passed 
into collapse and died — one on the 29th, and the other on the 30th. On the 
30 th, six deaths occurred at different places, in sight of each other : four among 
the flatboat population, and two persons who had arrived from New Orleans, a 
few days previously. By the first of January, a considerable number of cases, 
and several deaths, occurred at different points from one end of the landing 
to the other, under circumstances that rendered it impossible for the disease to 
have spread by actual contact, as the cases were too remote from each other ; 
and most of the subjects of them had neither been on an infected boat, nor in 
immediate contact with a case of cholera. To better understand the impossi- 
bility of the disease spreading so rapidly among this river population, by com- 
munication from one to another, or from direct communication with the steam- 
boats at the landing, it is necessary to be known that the principal steamboat 
landing is in front of the lower part of the city, and that the flatboat landing 
extends from the steamboat landing, along up the river, to the Navy Yard j and 
at this season of the year, when a large number of flatboats, laden with pro- 
duce, stock, &c, from the upper country, accumulate here, they stop above the 
city and the Navy Yard, so as to extend the line of flatboats nearly two miles 
in front and above the town. At the time the cholera commenced, there was a 
larger number of flatboats at the landing than usual, stopping here on account 
of the dread of the cholera below. The population connected with them, and 
with a few produce houses near the river, was estimated at about one thousand. 
Between this population and the steamboat landing, there was but little com- 
munication; so that, but few, if any, of those who were attacked, could either 
have been aboard of infected steamboats from New Orleans, or in contact with 
cases of cholera. This is rendered the more certain from the fact, that by 
the 2d of January, cases and deaths had occurred on different boats, from one 
extremity of the landing to the other; and one or two died at the upper part 
of the landing, a mile above town, who never had been, either down to the 
lower landing, or in town. 

Intervening between the town and the river, is a wide batture, which sepa- 
rates the population on boats from that of the town, except a few persons 
occupying houses near the river, three to six hundred yards from the town. 

Whilst the disease had thus extended itself the whole length of this line of 
population on the river, I neither saw nor heard of a case in town, which had 
not certainly originated at the river, except the case of the boy already men- 
tioned — who had been visiting the steamboat landing to sell fruit to the pas- 



1849.] Shanks on Pestilential Cholera. 17 

sengers — which occurred on the 2 1st, and a child two years old, that took 
sick on the night of the 80th, and died the next evening. 

This latter child was remote from the landing, in town, and no inquiry was 
made to ascertain whether it had been carried to a nearer point of exposure, 
to where the disease was prevailing, or not ; nevertheless, when I saw it, four 
hours before it died, it presented all the symptoms of complete collapse, to 
which state it had been speedily reduced by vomiting, and copious rice-water 
purging in the night. 

I have been thus particular in giving the facts, as to the time and the lo- 
calities of the occurrence of the first cases, because they go very far towards 
proving that few, if any, of cases that originated here, could possibly have 
been produced by actual contact with, or direct communication from, other 
cases brought from New Orleans. 

The inference, however, may justly be made, that the infection or poison 
which produces cholera is carried from place to place by steamboats departing 
from an infected port, especially when cases of the disease exist upon them; 
and that the infection or poison is thrown off from such boats, or transmitted, 
to a limited extent through the atmosphere, so as to produce the disease in 
persons strongly predisposed to it. 

As tending to render more convincing the evidence upon which this inference 
is based, it is proper to state, that the cases occurring all along the two miles 
of the Memphis landing, within a few days of each other, were bordering on 
the channel, along which the steamboats daily passed, and were, most probably, 
produced by the specific poison communicated from the steamboats, through 
the narrow space of damp atmosphere intervening between them; because, if 
they are attributed to an epidemic state of the atmosphere, or to local and 
malarious causes, it is exceedingly improbable that they would have been con- 
fined to this long line of immediate contiguity to the steamboat channel, with- 
out radiating sooner in other directions among the citizens in town. Besides, 
the inference made from the facts presented here, is strongly, if not conclu- 
sively, sustained by the additional fact, that since the commencement of cholera 
in New Orleans, on the 12th of December, up to the present time, more than 
two months, not a single instance has occurred, within my knowledge, from 
the most extended inquiry, of a case originating off from the borders of the 
rivers traversed by steamboats, in the whole extent of this great valley. But 
extending along the various navigable rivers from New Orleans, the disease 
has taken already an extensive range. Cases have not only been carried 
to, but have originated along Red River as high as Shreevesport — along the 
Mississippi, on the plantations along the coast, at most if not all the towns, 
and at most of the wood-yards and many plantations as high as St. Louis — 
along the Ohio river, at Louisville and Cincinnati, and along the Cumberland 
to Nashville, where it was (February 23 d) prevailing with considerable fatal- 
ity. This extended prevalence of cholera could not reasonably be supposed 



18 Shanks on Pestilential OJwlera. [July 

to confine itself so long and exclusively to the surface and the immediate 
borders of the navigated rivers, if any peculiar epidemic state of the atmo- 
sphere, extending so vast a distance, was capable of producing it without the 
aid of the specific poison disseminated through it, from a source of infection 
being brought contiguous to the various places where the disease has been de- 
veloped. It is certainly a fact, that during more than two months of prevalence 
of cholera, almost throughout this great valley, the disease has not extended, 
by the origination of cases, beyond the immediate borders of the principal 
rivers. Within three or four days after the first cases occurred in New Or- 
leans, all the boats leaving that port had cases among the crew or passengers, 
and thus the disease was speedily carried up all the rivers connected with New 
Orleans by steamboat communication. Not a single case, however, is known 
to have originated anywhere above New Orleans, on any of the rivers, before 
infected boats and persons sick or dead of cholera, were carried to the places 
where the disease was afterwards produced. 

Soon after the arrival of infected boats from that port, cases began to be 
produced at the various points where they landed, or passed sufficiently near 
to communicate the infection, occurring soonest and in the greatest number 
at the points nearest to New Orleans, and those most exposed by direct com- 
munication with the boats from that port. Going north from New Orleans 
in mid-winter, if cold has the influence generally conceded to it in checking 
the disease, the production, virulence, and diffusion of the poison, as they 
ascended north, would be diminished, and the production and extension of 
the disease less in proportion as they advanced in a northern direction. 

Now, so far this has all proved to be exactly true. Next to the city of New 
Orleans, the coast and the towns on the lower Mississippi have suffered most. 
Red River plantations and Shreevesport have suffered next most severely; 
then Memphis, Nashville, St. Louis, Louisville, and Cincinnati, in the succes- 
sion given, have suffered in proportion to their relative southern latitude and 
extent of communication with New Orleans, and boats from that port. 

As an example, out of many that might be given in proof of steamboats 
soon becoming infected and producing cholera far from the point where it was 
prevailing, and where they imbibed the infection, and far from any evidences 
of choleric atmosphere, the following is noted : Dr. H. started from Louis- 
ville about the first of January, on the steamboat Melodeon, to come to Mem- 
phis. The Melodeon ran in the New Orleans and Louisville trade, and was 
direct from the former port. At that time there were no cases of cholera in 
Louisville, except a few in the Marine Hospital, taken from the New Orleans 
boats. Dr. H. started from Louisville when there were no evidences of any 
choleric atmosphere or infection, except on the boats above Memphis. The 
evening before the boat arrived here he was attacked with cholera, and, by the 
time of its arrival here, was extremely ill ; he, however, went on to New 
Orleans, and recovered. On his return, about the 20th of January, he re- 



1849.] Shanks on Pestilential Cholera. 19 

ported these facts to me; and also that another gentleman from the upper 
country had been seized a few hours after him, and had died in ten hours 
after the first symptoms of the disease. 

Although inclining strongly to accord with the reports of health commit- 
tees, and the generally expressed opinions of physicians, throughout the 
world, that cholera is not contagious, or infectious, the careful observance 
of the facts connected with its production and prevalence in this widely 
extended valley, and a careful examination of the many facts furnished by 
the highest authority elsewhere, upon this subject, authorize the conclusion, 
that whilst it may in some countries seem to extend itself as an epidemic, 
in others, as recently in this valley, it has presented more the march of an 
infectious pestilence. 

The term infection is used in its most commonly received sense, to mean a 
specific cause of disease, that is readily transmissible through the atmosphere 
in certain conditions, to a greater extent than the virus of the more strictly 
contagious diseases; but always producing the same specific disease, and gene- 
rating or reproducing itself. 

Having alluded to facts elsewhere, confirmatory of those furnished here on 
this point, I shall only cite one or two which have been recorded from obser- 
vations made and reported on our own continent, withouf extending their 
accumulation from foreign sources. Dr. Dickson states, (Am. Med. Journ., 
vol. xiv.) "that the brig Amelia left New York on the 19th of October 
1832, for New Orleans. 

" Previous to her departure, some of her passengers were affected, but in 
six days the cholera was developed, and in eight days, 24 died. At this time 
she stranded on Folly Island, far out seaward, and about twenty miles from 
Charleston. This isolated healthy island was inhabited by four negroes. The 
captain, passengers, and crew, took refuge in the buildings on the island. 

u These, together with eighteen members of the Charleston Gruard, and a 
boat's crew of wreckers, who came to their assistance, made about 150 per- 
sons. Of the persons thus thrown together, all being healthy except those 
from the Amelia, who were affected with cholera, 23 died. Twelve of the 
passengers, six wreckers, and three of the four negroes, the nurse, and one of 
the city guards. Dr. Hunt, the attending physician, and the other seventeen 
city guards, were all, except one, attacked with cholera." 

This fact creates a strong presumption, that the disease was communicated 
by the sick crew and passengers of the Amelia, to the other persons on the 
island. 

Since the commencement of cholera in New Orleans last December, cases 
have been reported among the emigrants, on their passage from thence to 
California, at Chagres and at Panama; and the last accounts from Cali- 
fornia state, that an emigrant who died of cholera was buried with a cloak 
about him. The natives exhumed the body for the purpose of getting the 
cloak, and six of them died of cholera. 



20 Shanks on Pestilential Cholera. [July 

Taking the facts as they have "been developed, and now exist, in reference 
to the progress and propagation of cholera from New Orleans, almost the 
entire extent of the steamboat navigation of the principal rivers in the great 
valley ; and duly considering its invariable confinement to the surface and 
immediate borders of these rivers, though it has extended over many degrees 
of latitude, and several degrees of longitude, from the point of its origin; 
and that not a single case has originated anywhere before the arrival of an 
infected boat ; — we would ask, can these facts be reconciled at all with many 
of the theories, and opinions, as to its cause and mode of propagation? 

If cholera be not infectious, and communicable in that way, could a specific 
agent be forced from the bowels of the earth by subterraneous commotion, to 
the extent of all these long rivers, in so short a time, affecting only those 
persons on their surface, or immediate borders ? Could a deficiency of elec- 
tricity exist to so great an extent on all these rivers, as to produce a rapidly 
fatal disease, whilst the people but half a mile, or less from them, enjoy 
good health ? Could any peculiar epidemic constitution of the atmosphere, 
produced by meteorological, or subterraneous influences, or by animal or vege- 
table malaria from general warmth, dampness, or vicissitudes in the weather, 
alone, — in mid-winter, without any appreciable specific morbid cause operat- 
ing upon, or transmitted through it, produce a disease so malignant and 
fatal, extending thousands of miles along steamboat navigation on rivers and 
their immediate borders, without extending half a mile from them? 

The facts furnished by the propagation of cholera in this extensive valley, 
so far, seem to be irreconcilable with any of these theories. 

In addition to these theories, which have had not only able advocates, but 
their day of favorable consideration, I shall allude to a few others. Late ad- 
vancements in microscopic investigations, have established the fact in reference 
to some, and greatly increased the probability at least, that other specific dis- 
eases are produced by animalculi, or vegetable fungi, and the progress of in- 
vestigation promises to throw great additional light on this subject. Their 
almost incalculable reproductiveness would favour the conclusion that they 
might be produced and reproduced almost to any extent, from a comparatively 
small source ', and be carried and transmitted to a limited extent by the sick, 
their clothing, ships, boats, through the atmosphere, so, as not only rapidly 
to produce cases of cholera, but even to give it the appearance of an epidemic, 
and especially so in the summer, when open houses, and a greater evapora- 
tion from the sick, their evacuations, &c, would carry with the exhalations 
into the atmosphere, these invisible, but specific morbid productions, so as to 
extend the materies morbi, and its influence, with as much rapidity as cholera 
has ever spread. 

Dr. Cowdell, who adopts the theory of vegetable fungi as the morbid cause 
of cholera, and its more rapid and widely extended transmission, than that of 
the strictly contagious diseases, states, as to the reproductiveness of the cause, 
upon the authority of Fries, that a single one of the reticular ia maxima has 



1849.] Shanks on Pestilential Cholera. 21 

produced 10,000,000 sporules, that they are light and float rapidly through 
the air. He also states that the aptitude of these fungi for the human body 
is established by the fact, that they are found in various secretions and excre- 
tions in different diseases — in the fluid of pyrosis, in the exudations of puer- 
peral fever, and in dysentery — and that these vegetations exist in thrush. 

The production and virulence of cholera in low, damp, filthy, confined, and 
crowded places, and its general appertainance to such situations, are favorable 
to these views of its cause. 

Whatever may be the materies morbi, however it may be produced, all 
the facts attendant upon its present prevalence go to prove that, it is specific 
in its character and effects; and that it is governed by different laws from 
those which govern other wide-spreading epidemics, such as its frequent 
precursor or follower — influenza. For while one travels most rapidly, with 
the winds, and passes over hill and dale, affecting speedily the population of 
entire countries, the other, so far as its recent propagation demonstrates its 
mode of extension, goes only where it is carried by tangible objects, with 
which it is transported, and is reproduced by its own subjects — affecting, in 
its course, such persons only as are within a limited distance of its influence; 
and that distance seems to be intermediate, between that of the strictly con- 
tagious and the epidemic diseases. 

Another remark may warrantably be made in reference to the cause of cho- 
lera : that, like other specific morbid causes of disease, it has, in addition to 
its many other incidental effects, one universal tendency to affect the bowels 
in a peculiar way. The virus of small-pox, measles, chicken-pox, scarlatina, 
&c, tend universally to affect the skin, and to pass out of the body, each in 
its particular way, through that tissue : so, other specific diseases affect, in their 
peculiar way, other organs and tissues. 

This analogy between cholera and other diseases, particularly those which 
are contagious and infectious, and which transmit themselves in that way, 
is strongly corroborative of the specific, reproductive, and infectious nature 
of the cholera virus. It indicates another likeness to the specific diseases 
alluded to, which will be more particularly noticed in treating of its patho- 
logy, that, as in them, the poison which has impressed its morbific influence 
upon the blood, as well as on the nervous system, tends universally to be 
thrown off through a particular tissue and outlet of the body. 

These analogies and resemblances to the specific and infectious class of dis- 
eases, seem to entitle it more to be considered as a pestilence than an epidemic. 

4th. Symptoms and pathology of cholera. — I shall briefly give the prominent 
symptoms presented in the different stages of the disease at its commencement 
here, and such modifications as occurred during its prevalence, from the in- 
fluence of the weather and other causes, the post-mortem appearances, and the 
pathology upon which its treatment was based in the different forms which 
it presented in different cases. 

The first cases occurred among the flatboat population, who are subject to 



22 Shanks on Pestilential Cholera. [July 

diarrhoea from the effects of the Mississippi water, especially those persons 
coming from the Ohio valley. They were affected with diarrhoea from one to 
several days; and some of them, who had had slight looseness of the bowels 
for several weeks, dated the commencement of their attack one to two days 
previously to the occurrence of the spasms, as at that time they had an 
increased looseness of the bowels, the discharges became more frequent and 
copious, and more liquid and serous in appearance, without much uneasiness 
or pain, — each discharge flowing off easily, and followed for a short time with 
relief of the uneasiness of the bowels which preceded it. So insidious was 
the outset and first stage of the attack, in most cases, that patients could not 
be induced to believe by their friends or their physicians, that it was anything 
more than the ordinary river diarrhoea, such as they had frequently gotten well 
of before without medicine, and that they were really in extreme danger of a 
fatal development of cholera. 

This exemption from the feeling of being dangerously sick, or of there being 
any cause of alarm from the precursory diarrhoea, was such as to induce many 
to refuse to take medicine or consult a physician, until far advanced into the 
second stage of the disease, or even verging upon collapse — when the pain 
from cramps, thirst, sick stomach, and vomiting, became prominent and dis- 
tressing. This remarkable manifestation of indifference to, and insensibility 
of danger, seems diagnostic of pestilential cholera. 

I have seen cases in which the stools had been frequent and copious from 
one to two days, and had become thin as turbid Mississippi water — where the 
eyes were sunken, hollow, and injected; the extremities, face, and general ex- 
terior, shrunk, cool, or cold and bluish; the pulse feeble, or almost impercep- 
tible; the voice hoarse and weak, and cramps commencing in the extremities — 
and still the patients would insist that there was not much the matter with 
them, and if let alone they would soon get well without medicine. On visiting 
one case of this kind, I found the patient sitting up in a damp, confined cabin 
on a flatboat, blue, shrunk, and perfectly pulseless at the wrists, complaining 
only of cramps, and vomiting of the water, which his intense thirst induced 
him to drink freely. This man's system had been gradually, but completely, 
drained by the easy but copious serous discharges from his bowels; and 
though he then believed himself in no danger, in a few hours he was a corpse. 

The marked increase of a previous diarrhoea, or the commencement of the 
precursory diarrhoea, generally took place in the night, or early in the morning. 
The precursory or first stage generally continued, the stools becoming more 
and more copious and liquid, until the following night or morning; or, if the 
attack was less violent, until the second night; when the second stage was 
ushered in by vomiting and cramps, commencing in the extremities, generally 
the feet and legs first. The vomitings at first consisted of undigested food, 
but soon became copious and watery, and greater in quantity than the amount 
drank. The thirst, impairment of respiration and its functions, general en- 
' exvation of the system ; waning of the action of the heart and force of the 



1849.] Shanks on Pestilential Cholera. 23 

circulation, suppression of the secretion of urine, &c, followed, in these cases, 
in proportion to the time and the quantity of the discharge from the bowels. 

The second stage, in a longer or shorter time, from three to fifteen hours, 
dependent mainly on the quantity of the liquor sanguinis drained from the 
circulation, and the rapidity with which this took place, ran into the third or 
collapsed stage, which was marked by an almost or quite extinct pulse at 
the wrist ; by a cold, blue, shrunken, shrivelled, and sodden state of the gene- 
ral exterior, particularly the extremities and face; the features sharpened and 
the countenance much altered; the voice changed to a hoarse whisper; the 
tongue pale or bluish, cool or cold, generally broad and moist, with a thin 
white fur extending over it; the breath cool, or cold; thirst insatiable; the 
eyes hollow and injected, and, during intervals of quietude, only partially 
closed, generally showing the adnata, the balls being turned upwards; the 
secretion of urine entirely suspended; the absorption from the stomach and 
bowels suspended; the respiration generally slow, though sometimes hurried, 
but always oppressed and confined ; the functions of respiration, in the oxy- 
genation, and the change of the venous to arterial blood, and the consequent 
development of caloric much impaired; the mind rational and clear, but slow 
and feeble in its actions. 

After passing fully into this collapsed state, the purging, vomiting, and 
cramps gradually diminished, and in some cases almost entirely ceased for 
several hours before death took place. Death occurred, in cases where the 
spasms persisted, after the circulation was much impaired, suddenly, from a 
spasmodic affection of the heart and diaphragm arresting vital action; in 
others, and most commonly, from enervation of the whole system, resulting 
in insensibility and death. This collapsed state continued from a few hours 
to one or two days before it terminated in death. 

I have already stated that the first cases of cholera occurred at the close of 
a long continued spell of warm, rainy weather. On the 29th of December it 
cleared off, and from that time the weather continued dry, becoming so cold 
as to freeze pretty hard, during a continuance of fourteen days. Eight or ten 
days after the commencement of this dry spell of weather, when it was cold- 
est, such cases of cholera as I have described were suspended for several days. 
During these few days, the attacks were ushered in with uneasiness of the 
stomach and bowels, attended with a disposition to stool, the dejections being 
small; or with sickness and pain, or cramp, in the stomach, and vomiting of 
undigested food, without purging ; with giddiness or pain in the head, soon 
followed by a feeling of great prostration; the pulse slow and feeble; the 
surface and extremities cool; and cramp in the bowels, and sometimes in the 
extremities. These attacks were attended with so much suffering, that imme- 
diate medical aid was sought, and none of them terminated fatally, except 
one. The subject of this case, which occurred on the 10th of January, was a 
negro man of intemperate habits. When reaction began to take place, about 
nine hours after the attack, he complained of numbness in the entire right 



24 Shanks on Pestilential Cholera. [July 

side, without any pain, however, in the head, but intense pain in the bowels. 
As reaction increased, he became more and more stupid and insensible, and 
died apoplectic, about seventeen hours after the attack. 

On the 12 th, it had become warm and rained heavily, and the cloudy and 
rainy weather continued about a week. Soon after this rainy spell commenced, 
the cases assumed more of the previous and fatal character, with the profuse 
watery purging, &c. Within a few days after the commencement of the rain, 
several of the most sudden deaths occurred, the attacks commencing with- 
out the precursory diarrhoea; — purging, vomiting, cramps, and collapse en- 
suing so rapidly as to prove fatal in eight to twelve hours after the attack. 

Flatulence, indigestion, aching, or pain in the stomach and bowels, with 
and without diarrhoea, giddiness of the head, slight spasmodic twitchings of 
the muscles in various parts of the body, &c, were frequent during the pre- 
valence of cholera. In some degree, perhaps, every person felt the influence 
of the choleraic poison. 

In most of the cases when the vomiting, purging, and cramps were relieved, 
and reaction perfectly restored, followed by perspiration, and a restoration of 
biliary and urinary secretions, recovery invariably took place speedily, and 
without consecutive fever. 

But if reaction was incomplete, and a healthy perspiration and the other 
secretions were not restored, the appearances of amendment were generally 
delusive, and resulted in a typhoid form of consecutive fever, marked by a 
brick-red or bluish-red colour of the skin; dry and red tongue; thirst; indif- 
ference, gradually increasing to stupor; with slow pulse, and slow, heavy 
respiration, and finally coma and death. In such cases, neither the secretion 
of urine, nor a proper secretion of bile was restored, and they terminated 
fatally after this imperfect reaction, in from three to seven days. 

In other cases, however, in which the reaction took place, often from a less 
hopeless condition, under the use of stimulants exclusively, such extensive 
gastro-enteritic inflammation was produced, as to modify the progress of the 
case; and though both biliary and urinary secretion, and also perspiration 
were produced by proper means, still the case became protracted, presenting 
most of the symptoms of the more lingering cases of typhoid fever. These 
cases, though but few occurred, generally proved fatal. 

I treated two cases at the same time, in the same house, of middle-aged 
men of intemperate habits — one a second attack, in which reaction was im- 
perfectly obtained from a collapsed state, — the pulse feeble and small, the ex- 
tremities shrunk, cold, shrivelled, &c, and severe spasms with the congee stools. 
The pulse gradually rallied, becoming slow, and tolerably full, but soft ; the 
stomach retained drinks ; the skin perspirable and warm ; the complexion 
restored, except the brickish-red cast; the discharges from the bowels became 
consistent, but of a grass-green, gelatinous, or pultaceous character. All the 
symptoms improved for several days, except the entire suspension of the se- 
cretion of urine. The fourth day of this condition, the pulse and respiration 



1849.] Shanks on Pestilential Cholera. 25 

became slower, the tendency to stupor increased, and finally the patients died 
comatose on the sixth day after the commencement of reaction, without any 
secretion of urine. 

The suspension of urine occasionally continued two to four days, in persons 
who had not been so completely drained by the copious rice-water discharges 
as to produce complete collapse, without either seriously affecting the brain 
or interfering with recovery. I saw a gentleman of good constitution and 
habits, who had been treated in the second stage of the disease, without hav- 
ing had very copious purging, upon Hawthorn's sweating plan. He had 
passed more than a hundred hours without any secretion of urine, and with- 
out any action upon his bowels, or any evidence of biliary secretion. Some 
thirst, fever, headache, and considerable prostration existed. By a mild mer- 
curial alterative course, the biliary and urinary secretions were restored in six 
or eight hours, and he gradually recovered. 

In the different cases, stages, and grades of the disease, the discharges were 
various. The cases first described, in which the diarrhoea gradually increased 
until the copious evacuations drained the system of the serous portion of the 
blood, presented more unequivocally the congee or rice-water discharges. In 
some instances, in the commencement of the collapsed stage, they were as 
clear and inodourous as pure water; but, after standing a short time, they ex- 
hibited a loosely floating, filiform, flocculent matter. In other cases, especially 
when the disease supervened upon a chronic diarrhoea, the stools were offensive, 
and in appearance and consistence like dirty soap-suds, slightly frothy • and 
upon settling presented the appearance of thin gruel made of yellowish corn- 
meal, the upper part becoming clear and the turbid particles settling down in 
the vessel. In one case, in the collapsed stage, the stools were offensive, and 
resembled chocolate made with milk. In another case, after a sudden and 
violent attack, the discharges were suspended, by the remedies used, some 
twelve hours; and, when they returned, they consisted of copious bloody 
serum, which, upon standing, deposited loose coagula of gelatinous matter. 

The ejections from the stomach were first undigested food, afterwards 
mainly the fluids drank. No complaint was made of any prominent taste in 
the ejections from the stomach, nor was bile ever either vomited or passed in 
any case, in the uninterrupted course of the disease. In every stage of the 
disease previous to the consecutive fever, except in the two cases of collapse 
which I have mentioned, when bilious discharges from the bowels were ob- 
tained recovery speedily and certainly took place. In those two cases, 
although the discharges were dark-green and pultaceous, it is doubtful whether 
they were bilious, or were from the liver at all; and whether they should be 
set down as an exception to the rule. I have occasionally seen such stools, 
in bad cases of congestive fever, in which calomel had been given freely; and 
I have been satisfied that they were made up of morbid acid secretions from 
the bowels, produced by the calomel, and coloured by it, and that there was 
no biliary secretion at the time. They have generally, in congestive fever, 



26 Shanks on Pestilential Cholera. [July 

been unaccompanied with any improvement in the cases ; and have most com- 
monly indicated a fatal result. 

Post-mortem appearances. — It is needless to occupy much space in the 
account of these, as they were similar to those generally found elsewhere. 
The shrunken, blue, or marbled exterior ; the hollow eyes deeply sunk in the 
sockets ; the congested and brownish-red aspect of the interior ; the dark viscid, 
but uncoagulated blood accumulated in the cavities of the heart and large ves- 
sels, particularly the right side of the heart, the pulmonary artery, and the vena 
cava; the contracted state of the large bowels, their general surface lined with 
mucus, or a starchy matter; the contracted and empty state of the urinary 
bladder"; the gall bladder filled with a dark-coloured viscid bile, the liver show- 
ing no immediate change from the disease, except engorgement of its large 
vessels, with the dark and viscid blood; and all the common appearances de- 
scribed by the best authorities elsewhere, as the result of their autopsies, were 
found here. The case particularly mentioned of a negro man, who died apo- 
plectic, presented, in addition to the appearances already mentioned, great 
congestion of the vessels of the scalp, fulness of all the sinuses of the brain, 
and an effusion of several ounces of dark viscid, uncoagulated blood, between 
the dura mater and arachnoid membrane, on the upper and back part of the 
left side of the cerebellum; also a small effusion of serum in the ventricles, 
and considerable under the base of the brain and the spinal canal. The sec- 
tion of the cerebellum presented a remarkable number of black spots, showing 
altogether a very great degree of general congestion and effusion in the brain ; 
and accounting fully for the numbness of the right side, which commenced 
with the reaction, and also for the coma and death. 

The sensible character of the blood is peculiar in cholera. No discrepancy 
exists among writers, except that some speak of coagula in the cavities of 
the heart and large vessels, while others describe it as remaining, whenever 
accumulated in an uncoagulated state, dark, thick, viscid, &c, resembling, 
somewhat, molasses in its consistence ; and also, when drawn from the body; 
standing without coagulating, or separating into serum and crassamentum, as 
in health. 

The autopsies and observations made here, were confirmatory of the latter 
condition of the blood. 

Mortality. — From the commencement of cholera here, on the 29th of De- 
cember, in six weeks, as near as could be ascertained, in the city and suburbs, 
about one hundred died — nearly all in private practice, as the hospital is too 
remote for the accommodation of cholera cases. The cold, dry weather, which 
occurred soon after the commencement of the disease, doubtless lessened its 
propagation and fatality. Up to the present time, March 10th, sporadic cases 
continue to occur, and occasional deaths. 

This mortality took place in a population of ten to twelve thousand persons, 
and chiefly among negroes, and those white people, who, from their condition, 
ignorance, or indifference, either had not the means — did not know — or disre- 



1849.] Shanks on Pestilential Cholera, 27 

garded the plain directions furnished by the Board of Health for the preven- 
tion and for the cure of the precursory stage of the disease. 

The proportion of deaths to the number of cases could not be ascertained, 
as no reports were made of the latter. 

From my own observations, not only in my own cases, but also in those 
attended by other physicians, which were as much extended as possible, for 
the purpose of seeing the disease in all its stages, grades, and different aspects, 
embracing about forty of the cases which terminated fatally, and a propor- 
tional number of those cured, there was but little success in curing the dis- 
ease after perfect collapse, and cessation of the pulse at the wrist, though all 
the various means proposed for this condition were frequently and fully tried. 
I have seen myself but one recovery from pulseless collapse. 

In the precursory stage of the disease, numbers cured themselves, and the 
members of their families who were attacked, by the prompt use of the reme- 
dies directed to be used by the Board of Health ; and under personal medical 
attendance they were nearly all cured. 

In the second stage of the disease, the success was generally gratifying, par- 
ticularly if the necessary remedies were properly used before the system was 
too much drained by the rice-water discharges, and the waning pulse and 
shrunken features denoted the near approach of collapse. 

bth. Treatment. — On the treatment of cholera so much has been written, 
and is accessible to every medical reader, that more than a brief outline of 
the plan of treatment adopted, and considered most successful here, is unne- 
cessary. 

1st. Precursory stage. — This stage in its commencement was, doubtless, 
arrested and cured in many cases by various means — such as brandy, capsicum, 
laudanum, peppermint, camphor, &c, separately and combined; but after it was 
fully established, though the use of these means often suspended for a time 
the purging, it most commonly returned in a more aggravated form and re- 
quired other remedies in conjunction with them, to restore and correct the 
secretions and make the cure permanent. For this purpose, mercurials in 
moderate quantity, if not indispensable, were most efficient. In the crowd of 
business, for convenience and dispatch, finding it answer the indications well, 
I used a pill in this stage made of calomel 3 to 4 grains, camphor 1£ to 2 
grains, opium 1 grain, oil of capsicum half a drop, or capsicum 1 grain. These 
pills to be taken from one to four for the first dose, according to the urgency 
of the purging, and from one to two to be repeated every hour or two, until 
the uneasiness or pain in the bowels and diarrhoea are relieved ; their effects 
to be aided by a hot mustard foot-bath, close confinement to the horizontal 
position in bed, the use of warm, gently stimulating drinks, as sage, balm, 
ginger, or green tea, or toast, or rice-water, with bicarbonate of soda, and also 
by hot applications to the feet, and a mush poultice, rendered stimulating by 
the addition of pepper or mustard applied over the stomach and abdomen. 
After the purging was arrested, and perspiration restored by these means, if 



28 Shanks on Pestilential Cholera. [July 

the bowels remained constipated more than twenty-four hours, they were 
moved by a teaspoonful of turpentine, combined with one to two tablespoon- 
fuls of castor oil, which generally brought off bilious stools. During several 
days the diet was restricted to gruel, rice, tea and crackers, chicken water, &c, 
which generally established the cure. 

2d. Second stage. — Called on to institute treatment in the second stage, 
when the purging of thin muddy, or rice-water discharges, with vomiting and 
cramps superadded, indicated the urgency of prompt and efficient relief to 
prevent the pending and fatal collapse, I required a strict observance of the 
horizontal position in bed, as free ventilation as possible, to supply fresh air 
for respiration, and gave, instead of pills, which were too slow in dissolving in 
the stomach, for this urgent condition, the following compound powder: — 
calomel, camphor, and capsicum, each, equal quantities, and opium 1 grain to 
every 20 grains of the compound, all to be well pulverized and rubbed to- 
gether. Of this from 10 to 30 grains were given, according to the urgency 
of the symptoms, at a dose, mixed with from a teaspoonful to a dessertspoon- 
ful of laudanum when necessary, and washed down with a small quantity of 
cold water; and all drinks were prohibited until its impression was made on 
the stomach and general system. If vomited up, the dose to be repeated, and 
if the purging and cramps were not relieved, the dose to be repeated every 
half hour or hour, in such quantities, both of the powder and laudanum, as 
seemed necessary to control the symptoms. These remedies were aided by 
the hot mustard foot-bath, hot applications to the feet and back, a large blis- 
tering plaster applied over the stomach, &c. As soon as these means controlled 
the irritability of the stomach, warm drinks, toddy, toast water or teas, were 
allowed ad libitum. But while the stomach continues irritable, drinks of all 
kinds are almost immediately vomited up, and the thirst and vomiting are 
both sooner relieved when drinks are prohibited, and small lumps of ice only 
are allowed. 

The compound powder and the laudanum were given in quantities propor- 
tioned to the age, constitution, and ability of the patient to bear them, and 
the emergency of the case. When the serous discharges from the bowels 
were copious, though the number of stools may not have been numerous, with 
a tendency to speedy collapse, especially when accompanied with violent 
cramps, a large dose both of the capsicum powder, and in some cases 20 to 
30 grains of calomel additional, and the laudanum were given, repeated with 
or without the additional calomel at short intervals, if necessary to arrest the 
symptoms. At this critical juncture, when the physician is often first called, 
the life of the patient depends upon a correct judgment being formed of the 
dose which the patient can bear with safety; and the dose necessary should be 
given at once, and if it does not produce the effect desired in from three quar- 
ters to an hour, it must be repeated until the object desired is attained. The 
propriety and necessity of this prompt and bold practice when the treatment is 
commenced under these circumstances, are obvious — for one more stool — the 



1849.] Shanks on Pestilential Cholera. 29 

delay or loss by small and inefficient doses of one hour, may bring about fatal 
collapse. In addition to the other means, an enema of a gill of starch and a 
drachm or two of laudanum, or, what was more efficient and better retained, 
one to two drachms of laudanum with one drachm of spirit of camphor, ether, 
and aromatic spirit of ammonia, or essence of peppermint, each, combined with 
the starch, is a valuable auxiliary, both in arresting the discharges and rousing 
up and sustaining the nervous energies of the system. 

These means being successful in arresting the symptoms, and producing re- 
action, perspiration, and healthy secretions and excretions, the bowels were 
generally moved in due time, and the discharges were bilious ; but if the bowels 
continued locked up beyond twenty-four or thirty-six hours, castor oil and 
turpentine were administered, to open them. These results being produced, 
mild diluent, and, when necessary, gently stimulating drinks, and abstemious 
diet, generally perfected the case in a few days. 

3d. (Collapsed stage. — In the collapsed stage the same course was pursued, 
with the addition of twenty to forty grains of calomel to each dose of the com- 
pound powder. The additional large doses of calomel were given, not so much 
with a view to its direct effect in producing reaction, as to its well-established 
effects in allaying irritability of the stomach, arresting watery discharges from 
the bowels, and restoring secretion and excretion when reaction was produced 
by other means, and thus preventing consecutive fever. By the use of calo- 
mel in this way, when its wonted effect upon the secretions was produced, 
consecutive fever was invariably prevented, as the result of either the second 
or third stage of the disease; and the only troublesome secondary symptom 
to the patient, which occasionally occurred, was ptyalism. Indeed, this spe- 
cific effect of mercury, in any given ratio of doses and time, seemed more 
liable speedily to be produced in cholera when full reaction took place, than 
in any other form of acute disease. 

In a case of speedy recovery in a man about twenty-five years old, from a 
state of pulseless and apparently hopeless collapse, attended with violent cramps, 
I gave, as a first dose, about twenty-five grains of the compound capsicum 
powder, with thirty grains additional of calomel, mixed in a large tablespoonful 
of laudanum, washed down with a glass of brandy. In a few minutes it was 
vomited, by a spasmodic action, far across the room. The same dose was re- 
peated, and washed down by a swallow of cold water. The powder and lauda- 
num, in the same quantity, were twice more repeated in the space of an hour 
and a half, and no drinks allowed until the stomach was settled, and partial 
reaction indicated absorption, when diluent drinks, with a moderate quantity 
of brandy, were given freely. In addition to the other means already men- 
tioned in this and many other cases, a prompt and important effect was pro- 
duced by woollen cloths wrung out of nearly boiling hot water, and applied to 
the stomach, spine, and extremities. After the three doses, laudanum alone 
was given, in teaspoonful doses, at intervals of two to four hours, until the 
No. XXXV.— July, 1849. 3 



30 Shanks on Pestilential Cholera. [July 

cramps were relieved. In eighteen hours, this man took from an ounce and a 
half to two ounces of laudanum. The next clay he was much better, though 
he had slept but little, and evinced no decided effect from the laudanum, 
except itching of his nose and of the surface generally. The following day 
he was well enough to sit up, and recovered speedily, with but a slight affec- 
tion of the gums from the calomel. 

So large an amount of opiate was not given in any other case. The result, 
however, proved that, though it was retained in the stomach, and absorption 
was re-established in a few hours, still the feeble state of the circulation, and, 
for a time, the want of supply of the healthy and necessary amount of arte- 
rialized blood in the brain, prevented the ordinary effects of the opiate from 
being produced on the brain and nervous system. 

Being fully convinced, from many years of careful observation, of the im- 
portance and necessity of the free use of opiates and calomel in congestive 
fever, of the continued form, — from the pathological likeness of cholera, the 
same practice to some extent was adopted. 

In cases of congestive fever, coming on as they frequently did here, eight 
or ten years since, with lassitude, slight chilliness, sick stomach, vomiting, pros- 
tration, &c. : vomiting and thirst increasing in the same ratio with each other j 
the pulse waning ; the surface and extremities becoming cold, with increasing 
complaint of oppression and internal heat • — though in some few cases this 
complaint of heat was absent, and the tongue and breath were cool ; — the pulse 
gradually diminishing down to a thread ; the surface wet with cold, clammy 
perspiration ; the skin shrivelled and sodden, as in cholera, but never so blue 
and marbled j the mind generally clear ; but during the development of this 
category of symptoms, which required from three to five days to arrive at 
their acme, without any evidence of paroxysms, except an increase of oppres- 
sion, frequency and feebleness of the pulse in the evenings, there were almost 
invariably great torpor and obstinate constipation of the bowels. 

In these cases, opiates were tolerated and required in large doses ; and my 
practice has been to administer them in combination with calomel, so as to give 
ten to twenty grains of the latter three or four times a day, with as much of 
the former as was necessary to relieve the concentration of nervous irritation 
upon the stomach, and to sustain the innervation of the brain and general 
system, until the action of the nervous and vascular systems were equalized 
by the influence of the opiates, and other appropriate means, and permanent 
healthy action secured by the general alterative and stimulating effects of the 
mercury upon the secretory and excretory organs. 

This practice has been so uniformly successful in the condition of the sys- 
tem described, that I have seen no reason to change it for any other ; though 
to make it so, in extreme cases, an amount of opiates equal to twenty grains 
of the gum in twenty-four hours might be required. 

In cases of extreme irritability of the stomach in congestive fever, when 



1849.] Shanks on Pestilential Glwlera, 31 

the internal use of opiates failed to control it, and the general restlessness, after 
blistering the precordial region, the external application of morphia acted 
promptly and efficiently. This is more the case in cholora, and is a means 
of more value, when there are great depression and restlessness, and the stomach 
continues to be irritable, and no absorption is taking place from the stomach 
and bowels, than almost any other. 

In the collapsed state of congestive fever, ice rubbed over the extremities, 
and the parts to which it is applied wiped dry, and well rubbed, and this fol- 
lowed by external heat, to be repeated every half hour or every hour, is a 
valuable means of restoring excitability and producing general warmth and 
reaction. This remedy used in cholera, when the system was not too much 
drained, and the blood rendered too thick to be invited back into the superfi- 
cial capillaries, is decidedly valuable. But in the collapsed stage, when the 
blood has retired from the extremities and surface, it has failed to do more 
than temporarily improve the colour of the skin, and revive for a transient 
space of time the slight evidences of circulation that still existed. Like all 
other means in that condition, generally it fails in producing any permanent 
benefit. 

No other disease, except sporadic cholera morbus, presents so many resem- 
blances to epidemic cholera, as this continued form of congestive fever, in its 
symptoms, pathology, and treatment ; though in it the profuse purging and 
cramps characteristic of cholera are wanting, and indeed in most cases the 
bowels are torpid; yet the general likeness is often striking, and, compared 
with cases described by Mr. Thorn and others, on the Ganges, where cholera 
collapse and death sometimes occur without purging, the resemblance is still 
greater. 

Now this form of congestive fever is clearly the effect of malarial influences, 
and it is peculiar to low, damp, and malarious regions. The specific virus of 
cholera tends universally to affect the bowels and produce watery passages 
and cramps, and thus to constitute striking diagnostic symptoms between it 
and the most malignant forms of malarial fever. There seems to be no good 
reason, however, to disbelieve that the cholera virus and malaria may co-exist 
and conjointly act upon the system ; and indeed, the fact that the cases of 
cholera which result speedily in collapse, without any purging, thus resembling 
pernicious fever, are only reported by physicians who have witnessed the dis- 
ease in highly malarious and hot regions, such as the Delta of the Ganges, 
strongly corroborates their conjoint effects upon the system, and the occasional 
predominance of the malarial influence, in the production of such cases. 

The ataxic cases which occurred here during the cold dry weather, were 
attended with pain in the head, stomach, and bowels, and prostration, without 
much, and in some cases without any purging; the pulse slow, 40 to 60, and 
soft; the surface cool, and the extremities cold and cramped. 

Opiates in these cases, and especially when the cepblalagia was severe, could 



32 Shanks on Pestilential Cholera. [July 

only be used with great caution. The abstraction of blood in this condition, 
and in this form of the disease only, seemed indicated and useful to develop 
reaction, and aid in equalizing the circulation and restoring healthy secretion. 

Mi. Consecutive stage. — When the plan of treatment I have given was 
adopted and properly carried out, in the previous, or three stages proper to 
cholera, consecutive fever rarely occurred; but, treated exclusively with ano- 
dynes, astringents, and stimulants, the recoveries were more apt to be slow, and 
attended with want of proper secretion and with gastro-enteritic inflammation, 
presenting a more or less protracted case of a typhoid form of fever. The 
treatment of this condition requires the use of alteratives, diluents, diapho- 
retics, &c. ; a careful attention to the condition of the brain, to prevent a deter- 
mination of the disease to that organ. 

The importance and effect of a few of the prominent remedies in the treat- 
ment of cholera, deserves a passing notice. 

Opium and Calomel. — Much importance has been attached to the free use 
of opium and calomel, especially in the second and third stages of cholera. 
While, in the precursory stage, they are important to moderate and arrest the 
purging, and at the same time to correct the morbid secretions, in the second 
and third stages the life of the patient depends upon the attainment of these 
objects in the shortest possible time. 

To effect these objects, both observation and analogy prove that no other 
remedies are so efficient and certain, as opium and calomel. The want of 
ordinary susceptibility of the nervous system to the impression of remedies; 
the suspension of absorption from the stomach and bowels ; the regurgitation 
of the chyle, and the rapid pouring into the stomach and bowels of the liquor 
sanguinis from the general system, carrying out speedily all the remedies 
given either by vomiting or purging, and by this current of determination to 
the bowels preventing their absorption and diffusion through the system; all 
show the indispensable necessity of large doses to secure the desired object. 

The opiates — and laudanum, or morphia, from their more prompt action, 
are best — must be given in large doses, sufficient to arrest the discharges. 
Other effects, not much less important in this condition, are more certainly 
produced by it than any other remedy. It sustains the nervous energies and 
the action of the heart ; it relieves local irritation and cramps, and equalizes 
innervation, and thus helps the system to rally under the depressing influence 
of the morbid poison. For the additional effort, of safely eliminating the 
poison from the system, and correcting the morbid secretions produced by 
its influence, the great weight of medical authority, and my own experience, 
are in favor of calomel above all other remedies. It must, however, success- 
fully to meet the emergency, be given in large doses, and immediately with 
the laudanum, so that no time may be lost in securing its alterative action. 
To the inexperienced, the use of calomel in large doses, when there is copious 
serous purging, might seem a paradox; but who that has almost invariably 



1849.] Shanks on Pestilential Cholera. 33 

found a full dose of calomel, uncombined with opium, arrest the frequent 
watery discharges in ordinary diarrhoea, and gradually give them healthy 
consistence, could doubt the propriety and importance of its use in this con- 
dition, with a view to its alterative effects? 

Large doses of opiates are warranted, and proved to be safe in this condition 
of the system, not only by ample experience, but from analogy. If the case 
terminates fatally, nothing is certainly determined as to the relative effects of 
the remedies used, and the disease upon the system ; because, when it is ex- 
hausted by the discharges, the general enervation results in insensibility and 
death, without the use of opiates j this insensibility and stupor which imme- 
diately precedes death may be attributed incorrectly to the effects of the opiates. 

But when a violent case is treated by the free use of opiates, such as the 
case of complete collapse reported, then and then only can the favourable, or 
unfavourable effects of this remedy be fairly and fully determined, by the clear 
manifestation of its effects. 

In cases of feeble action of the heart, and deficient supply of blood to the 
brain, either from hemorrhage or from other causes, large doses of opiates 
are not only safely tolerated, but required to sustain the system, as in uterine 
hemorrhage, mania-a-potu, congestive fever, &c. 

For the purpose of stimulating and constringing the exhausted surface of 
the stomach and bowels, and also rousing up and sustaining the depressed 
nervous energies of the system, and producing reaction, capsicum, camphor, 
spirit of ammonia, brandy, and various other stimulants and aromatics are 
valuable auxiliaries. 

Another very important requisite deserves to be more particularly noticed 
in the successful treatment of cholera, after the system is at all exhausted 
by the discharges of its white blood ; absolute confinement to the horizontal 
position in bed. 

In no condition except after profuse hemorrhage, is the effect of the erect 
posture so immediately manifest in producing faintness, sick stomach, en- 
feebled pulse, &c, as in cholera. In a state of partial reaction, and a favour- 
able and promising change in the symptoms, after great exhaustion from pro- 
fuse discharges, I have seen all undone, and the fatal collapse reproduced by 
the patient's assuming the erect posture on getting out of bed. 

Prophylaxy. — Enough has already been said about the peculiar habitudes 
of the cholera virus ; the favourite localities and situations for its development 
and propagation, in places which are low, damp, confined, and filthy. Obviat- 
ing by every means these unhealthy conditions of the atmosphere, or removal 
from such localities, are the important measures necessary to lessen or to avoid 
its virulent influence. 

The more immediate means of protection against an attack of the disease, 
consist in being surrounded as far as possible by all the comforts of life — such 
as dry, airy houses, warm clothing, the avoidance of exposure or fatigue, 



34 Shanks on Pestilential Cholera. [July 

nourishing and digestible food, taken at regular intervals, and regular hours 
of rest and exercise, or attention to business. 

When cholera is prevailing as an epidemic, those persons who enjoy these 
advantages, and avail themselves strictly of their observance, are but little 
liable to severe or fatal attacks. In addition to these precautionary and pro- 
tective measures, the introduction of cases of the disease into crowded houses, 
where proper ventilation and cleanliness cannot be secured, as far as possible 
should be avoided ; and, when cases occur under such circumstances, if practi- 
cable, they should be removed. 

Soon after the commencement of cholera here, a case was taken from the 
flatboat landing into a filthy and crowded house. After a severe and protracted 
illness he recovered. But, during his illness, other cases occurred in the house, 
and the disease progressed among the inmates, consisting of several families, 
until twenty-seven out of thirty persons were affected with it, and several 
relapses occurred. Finally, nearly all were removed from the house, when 
they speedily recovered. At the time this large proportion of cases occurred, 
out of whom six died, excepting in two adjoining houses, there were no other 
cases in the vicinity, although it was near the centre of the town. 

Proper attention to these means will secure, in a great degree, immunity 
from the disease; whence it is that the chief fatality from cholera occurs among 
that portion of the population who either cannot or will not attend to their 
observance. 

When, however, attacks do occur, it is a matter of the greatest importance 
to attend promptly to the first symptoms. By immediately and properly treat- 
ing the first symptoms, except now and then a case occurring under the most 
unfavourable circumstances, none should prove fatal. There is no mortal dis- 
ease in which the healing art presents so certainly the life-preserving balm as 
in cholera, if early and properly used. But so insidious and rapid is the pro- 
gress of the disease, that many fall victims to it from not knowing or feeling 
the importance of its early treatment. 

Philanthropy, and every proper consideration connected with the useful- 
ness of the profession, require that, in reference to this disease especially, all 
proper means should be used to enlighten the people, both as to the proper 
and best prophylactic means to be observed, and also the importance of the 
early use of these remedies. 

Memphis, 1849. 



1849.] Parkman, Extracts from Soc. for Med. Improvement. 35 



Art. II. — Extracts from the Records of the Boston Society for Medical 
Improvement. By Samuel Parkman, M. D., Secretary. 

April 9th. Cerebrospinal Meningitis. — Dr. Joseph Sargent, of Worces- 
ter, read the following cases of this disease, epidemic in the town of Sutton. 

The following are memoranda of an epidemic of cerebro-spinal meningitis in 
the towns of Millbury and Sutton, in March last. They are collected mostly 
from medical gentlemen in whose practice the disease occurred. They do not 
reach the accuracy of recorded bedside observations, but were related only 
memoriter. They come nearer the truth, however, for being observations of 
a disease that is rare, and which attracted a good deal of attention and remark. 

Case I. — E. L., aged 55, was a scythe-maker in Millbury, and occasionally 
an auctioneer : a large, healthy man of temperate habits, and in good flesh. 
The invasion of the disease was on Saturday, the 26th of March, and not 
after any unusual work or disturbance. 

March 2bth. He had worked at his trade all day, and served in the evening 
as an auctioneer. He had slept well that night; and the morning of the 26th, 
after taking a light breakfast, as usual, at 7 A. M., had gone to his work, 
from which he returned at 8 o'clock, complaining of "aching of the bones." 
He was up and down during the forenoon, talking as usual, and without any 
dulness, though with some headache. Took a cup of tea for his dinner. In 
the afternoon his headache became so severe, that he called for an application 
of spirits of camphor. Took a cup of tea with his family at evening, and 
had a comfortable, quiet night: not talking, groaning, or snoring in his 
sleep. Had had no nausea, and the bowels were open. Sunday morning, 
the 27th, he rose at 7 o'clock, complaining of very severe headache. Ate no 
breakfast ; had a chill soon after he was up ; and, now, the headache became 
so severe, that he said he had never known what headache was before. Dr. 
Corlew, of Millbury, was called in at 10 J A. M. He reports that he found him 
lying quietly on his left side in bed, with the knees bent, and respiration not 
labored nor hurried. His pulse was 85, apparently full, but easily compressed. 
Skin universally flushed, hot, dry ; greatest heat about head. Pupils equal, 
moderately dilated, not contracting to light. The patient seemed to be only 
partially conscious. Being asked to put out his tongue, would protrude it and 
not retract. Being asked if his head ached, said "a little;" did not seem to 
be conscious of any great pain ; mistook morning for evening, and repeated 
the mistake when corrected. His tongue was dry, glossy, very red. Dr. 
Corlew advised frictions with strong mustard water; sinapisms to calves of 
legs; cold to head; and pills containing blue pill gr. x; comp. extract of 
colocynth, gr. xv; rhubarb, gr. xv. 

Dr. Corlew saw him again at 1 P. M. The purgative had moved the 
bowels twice, smartly, producing dark fluid evacuations. His skin was now 
universally pale and cold, especially on extremities. He was lying on his 
back, quietly, with the limbs extended, the eyes closed, the pupils contracted, 
obedient to the light ; seemingly entirely insensible to what was going on 
around him. He talked incoherently : blowing the bellows, fishing, &c. His 
pulse was 100, and very small. Dr. Corlew advised : continuance of mustard 
applications ; blister to lumbar region ; frictions over spine with quadruple 
ammonia; Dover's powder, gr. ii; calomel gr. i, every hour. 



36 Parkman, Extracts, from Soc. for Med. Improvement. [July 

Dr. Corlew saw him again at 5 P. M. He had now spoken none for two 
hours, and had kept his mouth nearly closed, so that his medicine had been 
forced. He was in great and almost constant jactitation, so that two strong 
men could scarcely keep him on the bed ; no rigidity. The frictions had pro- 
duced but very slight irritation. 

I saw the patient with Dr. Corlew at 5 J to 6 P. M. I found him pale, cold, 
in great jactitation, without rigidity; mouth very slightly open, tongue palish, 
glossy; jaws not admitting of easy separation; groaning and moaning, taking 
notice of nothing, using no words. Pulse 100 to 108, counted with difficulty 
on account of the jactitation. Pupils of about natural size, examined with 
difficulty; no injection of conjunctivae or of other visible tissues of eyes. 
Advised continuance of treatment. 

Patient remained much in this condition till the morning of Tuesday, the 
29th of March at 2 o'clock, when he died — 66 hours after the probable in- 
vasion of the disease. On Monday, considerable irritation had been produced 
over the spine by caustic potass. 

Post-mortem examination, &Q[7wurs after death. The body was mottled by 
large ecchymoses. Two to three inches of adipose substance over abdomen, 
and nearly as much over thorax. Viscera of thorax and abdomen examined 
carefully, present no abnormal appearance. Lungs, healthy and crepitating; 
valves of heart normal; spleen, small; liver, of usual size and appearance; 
kidneys, do: All the abdominal organs inlaid in adipose substance ; no eleva- 
tion of Peyer's patches. 

Upon opening the cranium, there was no unusual adhesion of the dura 
mater, which presented its ordinary appearance, and preserved its polish on 
the arachnoid side. Under the cerebral arachnoid, over the upper surface of 
both hemispheres, was seen a whitish deposit, as of purulent matter. On 
attempting to remove the arachnoid, the pia mater came with it, the two co- 
hering so closely as not to admit of separation ; and the purulent deposit was 
between them. On both sides of the cerebellum there was a considerable 
intermeningeal deposit of pus and lymph, also. The membranes having been 
detached from the cerebrum, it had not its usual whiteness and polish, but was 
dull and punctuated, like the inside of a strawberry, and on being scraped was 
found to be somewhat softened. The cut surface presented an unusual num- 
ber of red points. The cerebellum seemed healthy ; no unusual fluid in ven- 
tricles. No pus seen along medulla oblongata. 

The spinal marrow being exposed from the front, at commencement of dor- 
sal vertebras, a considerable deposit of pus and lymph was found without soft- 
ening of marrow. At middle of dorsal vertebrae there was another similar 
deposit with softening of the marrow. 

This examination was conducted hastily, in the time between the passing of 
two trains of cars; but the account is reliable in so far as it goes; I present 
the case first, although it was not first in order of time, because I saw it in 
life, and have the history accurately, and assisted, also, at the post-mortem 
examination. 

Case II. — A. G-., aged 47, single, and a healthy man, a farmer and teamster, 
complained a little of "aching of the bones" on Saturday, March 3cZ. This was 
much increased on Sunday the 4th, but he slept well Sunday night. He woke 
early Monday morning, the bth, complaining severely of headache, backache, and 
aching all over. At 8 o'clock, Dr. Corlew found him lying on his left side, 
with his head near the edge of the bed, his arms over the side of the bed, his 
legs flexed, his pupils much dilated, knowing nothing, with entire loss of mus- 



1849.] Parkman, Extracts from Soc. for Med. Improvement. 37 

cular action, so that his hand raised would drop. His pulse was 80, small 
and easily compressed. Head not very hot j general heat, natural. Respira- 
tion not laboured. He was lying like a man in quiet sleep, and could not be 
roused. Dr. Corlew advised sinapisms to the epigastrium, back, and legs, 
and an emetic of ipecac, and calomel. The patient resisted, in a dogged 
manner, all medical or other interference. He was restless, tossing about, 
saying, " oh dear I" getting up, walking across the floor, putting his hands on 
to his back, revolving his body in a rigid way, sitting down like a man with 
a stiff neck. While he was in this state I was called to him ; but before I 
reached Millbury (namely, before noon), his condition was considered as being 
improved (this being the first case of the disease in its epidemic form), and I 
was not desired to examine or prescribe for him, but was called away by Dr. 
Corlew to advise for a child in similar state, whose case, also, I shall here 
report. 

The appearance of the man, thus far, had been such as to cause his neigh- 
bors to explain it by calling it a manifestation of " ugliness" rather than of 
disease — such was his restlessness and apparent spirit of rebellion. His 
emetico-cathartic having done its work, Dr. Corlew placed him, the next morn- 
ing, upon Dover's powder and calomel, and the third day upon opium and 
camphor, of each one grain every three hours. This course seemed to afford 
some relief to his aching, but he was constantly in a half conscious state, 
answering questions accurately for a moment, and then talking to himself, 
driving his team, walking about and saying "oh dear, how I ache — how my 
back aches," till about the tenth day, when he sank into a typhoid state, with 
rigidity and opisthotonos. He lay on his back, constantly slipping down in 
bed. He answered questions irrelevantly. He had subsultus tendinum, and 
picked at the bed-clothes, and passed his urine in bed. He had a red dry 
stripe down the middle of the tongue. I saw him on the twelfth day of his 
disease, when all these symptoms were manifest. Some days before, if an 
attendant stepped towards him quickly, or thrust his hand towards him, he 
would retract, as if to dodge. He died on the thirteenth day of his disease — 
March 16. 

A Post-mortem examination was made on the morning of the day following, 

The body was large; limbs rigid. On opening the head, the veins of the 
meninges were found to be turgid with dark blood. There was no unusual 
serous fluid below the arachnoid, but here and there, between the convolutions 
of the cerebrum, there was a whitish deposit, which, on the removal of the 
membranes, was found to be between the pia mater and the arachnoid, dipping 
down between the convolutions, and being of the consistence of lymph. 

The membranes were easily detached from the cerebrum, leaving its surface 
white, polished, and of the ordinary firmness. It is rare to see the cerebral 
substance harder; and the consistence was uniform; and the cut surface pre- 
sented no unusual red points. The right lateral ventricle was distended with 
a serous fluid, containing flocculi of lymph and pus. The choroid plexus was 
reel, like the comb of a cock. On removing the right hemisphere of the cere- 
brum from the skull, the anterior lobe presented an intermeningeal deposit of 
pus and lymph, of an inch in irregular diameter immediately over the orbit. 
The sella turcica was covered in like manner, and the optic nerves enveloped 
— the nerves themselves preserving their ordinary consistence. The right 
hemisphere having been removed, the deposit of pus and lymph dipping down 
between the convolutions on the other side, in situ, was quite remarkable, 
Neither tubercles, granulations, nor ramollissement, were found anywhere. At 
the base of the cerebellum and about the medulla oblongata, there was a good 



38 Parkrnan, Extracts from Soc. for Med. Improvement. [July 

deal of lymph, with abundant pus, also; and this could be seen along down 
the spinal marrow as far as the eye could penetrate, all being bathed in pus. 
The spinal marrow was then exposed in front from upper dorsal vertebra to 
sacrum, and everywhere there was abundant pus between the pia mater and 
the arachnoid, especially on the posterior part, so that it could be spooned out. 
The spinal marrow itself and the nerves were quite firm. The right sciatic 
nerve, exposed by an incision through the gluteal region, presented nothing 
abnormal. 

The lower lobe of the right lung was in a state of red hepatization — florid, 
solid, heavy, friable, containing no air. Lungs, otherwise, entirely healthy. 
Some subsidence posteriorly. 

Spleen small; pancreas, and kidneys, and liver, presented nothing unusual; 
intestines, examined throughout their whole track, presented nothing abnormal; 
no development of Peyer's patches; the bladder was distended with urine. 

Case III. — The only other post-mortem examination was made by Dr. Henry 
Sargent. The case was of a child in Sutton, aged five years, which died eight 
hours after the apparent invasion of the disease. There was nothing abnormal 
found in the examination, excepting a turgid state of the meningeal vessels, 
and a pulpy condition of the spinal marrow. The body was covered with 
purple petechise, a line or so in diameter, and not raised. The same were 
found on the peritoneal face of the stomach, and were confined to the perito- 
neum. I regret that I have no detail of the symptoms in this case. This 
little child's grandmother died in the same house the day following, of similar 
disease. No post-mortem examination was allowed. 

Case IV. — C. L , aged 3 J years, complained, Saturday afternoon, 

March 3d, of severe pain in the head, and vomited. The vomiting continued 
at intervals till the next afternoon. Dr. Corlew found the child, Sunday 
morning, at 10 \ o'clock, in the following state, viz.: quiet, stupid; head and 
body hot; respiration natural; pulse quick; pupils dilated, not obeying the 
light. The tongue was red. At 1 P. M. the stupor had passed away, and there 
was partial consciousness, jactitation, contraction of pupils, rigidity of neck. 
I saw her on Monday — when there was jactitation, contraction of pupils, rigidity 
of neck, uncertain vision — the little patient putting her hand forward for my 
purse, which I held out for her, but missing it. She died on Wednesday, 
about ninety-six hours from the attack; no autopsy; no tubercular disease in 
family. 

The aforegoing cases represent the epidemic, of which there have been six- 
teen cases within the circuit of four miles of a country not very thickly settled, 
and no recovery that can yet be relied on. There has been a striking similar- 
ity of symptoms in all the patients. Death occurred in one instance in six 
hours from the attack. The patient who lived longest is the one whose autopsy 
is reported — the death having occurred on the thirteenth day. Most have died 
within four days, and three within twenty-five hours. 

In Miilbury all have been males but one ; in Sutton three were females. 
(Dr. Corlew is not sure that there were not more than three.) In Miilbury 
the disease has been, for the most part, within a few rods from the Blackstone 
River ; and, in one instance, there were two cases in one house. In Sutton 
the cases have been in various parts of the town, high and low. 



1849.] Parkman, Extracts from Soc. for Med. Improvement. 39 

Dr. Paine of Oxford, whose practice reaches also into Sutton, reports to me 
the following cases : — 

Gr. W— , aged sixteen, was not well, March 9th, though at school. He 

complained after school of pain in his head and was chilly, and had not much 
sleep in the night. The morning following there was pain in the head and 
limbs, and soreness of the flesh. In the afternoon Dr. Paine found him pale, 
cold, senseless, with dilated pupils (unequally dilated), moaning, and in a good 
deal of jactitation. He used no words. The Doctor gaye ipecac, applied 
mustard largely, and ordered J gr. calomel every hour. The next morning he 
had aroused a little, so that he knew the Doctor, and was for the most part 
rational, and had some warmth of the extremities. This continued during the 
day. At night he was hot, restless, sleepless, delirious, and so for the follow- 
ing day and night \ after which his delirium gradually wore away. He had 
opisthotonos on the 14:th, and double vision after restoration of reason; also 
considerable pain in the back. This young man is still (March 30th) under 
Dr. Paine's treatment — the same having consisted mostly in calomel and 
counter-irritation. [This case is not counted among the sixteen reported to 
me, in a manner, by Dr. Corlew.] 

Dr. Paine reports another case, of a woman, aged thirty to forty, attacked 
on a Sunday and dying the next Friday, having never got out of the cold stage, 
nor reached consciousness. She took a good deal of powerful cathartic medi- 
cine, and was blistered over the spine of the neck and back. Dr, Paine saw 
her daily, in consultation. Her symptoms were like those of the last patient. 

Another patient of Dr. Paine's, a hard-working, energetic, not very strong, 
woman, of sixty to seventy years of age, slender, of more than middling height, 
was taken, Sunday, March 20th, with pain in head, vertigo, pain in limbs, and 
soreness and chilliness. The pain in head continued till her death, Thursday 
night, the 24:th. There was no delirium till the morning of the 23d, and then 
it was only occasional. There was strong opisthotonos, no dilatation of pupils, 
no noise in head, no paralysis, very little sleep, a great deal of jactitation. 
The bowels were easily moved by cathartics. The Doctor gave calomel, four 
or five grs., with a little ipecac, once in six hours or so, and made use of ex- 
tensive counter-irritation. The treatment seemed to have no effect upon the 
disease. 

Another patient of Dr. Paine's, a boy of four years of age, went to bed 
well, and waked in night delirious, and much frightened. Dr. Paine found 
him, the next morning, in bed, on his back, pale, cold, and with dilated pupils. 
The neck, chest, and abdomen, were covered with irregularly rounded purple 
petechia, of about a line in diameter, not raised and not disappearing on pres- 
sure. The intervening skin was the whitest Dr. Paine ever saw; and the veins 
on the abdomen and chest were dark purple, distended, and distinct even in 
their minutest ramifications, presenting a dark net-work in beautiful contrast 
with the perfect whiteness of the skin. The pulse could scarcely be felt. 
Convulsions soon came on, and the boy died within three hours from the time 
of Dr. Paine's first seeing him. The petechia covered the extremities also 
before death, but did not appear on the face. 

Three days after, Dr. Paine was called to the mother of this child, complain- 
ing of her head and back and limbs, and of chilliness, and presenting the same 
petechia. After active purgative and counter-irritant treatment she was about 
work on the second day. 

Three days after this, Dr. P. was called to another of her children, aged two 
years, in convulsions, and presenting the same eruption. This child is still sick 



40 Parkman, Extracts from Soc. for Med. Improvement. [July 

(March 30th), and has had opisthotonos and dilatation of the pupils, and, at 
first, some loss of consciousness. 

I have introduced these latter cases of Dr. Paine's to suggest a comparison 
between this disease and the " Spotted Fever," so called, as described by Dr. 
Hale, Dr. EL B. C. Green, and others, and especially in the American edition 
of Copland's Medical Dictionary, as published by the Massachusetts Medical 
Society, under the article " Fever." This is the description of a disease with 
strongly marked cerebral symptoms ; and the only autopsy I find recorded, 
(viz., that of Dr. Bowen's patient,) is an autopsy of cerebral meningitis, while 
the general account of post-mortuary appearances, in other cases, speaks of 
meningeal vessels turgid with blood, of adhesions between the two hemispheres, 
of bloody points on the cut surface of the cerebrum, and of distension of the 
lateral ventricles. My attention was first called to this, by remarks of Dr. 
John Green, a physician who was in large practice in Worcester and vicinity, 
during the prevalence of the epidemic of u spotted fever," in Worcester County, 
(1810 to 1814,) and who stated the analogy of symptoms before any autopsy 
had been made. The " spots" play but a very subordinate part in all the his- 
tories of the epidemic of thirty years ago, that I have seen, and were by no 
means constant. They gave the name to the epidemic only because its lesion 
was not known, and the name was picturesque. The name also made, perhaps, 
a part of its terror, and designated a kind of personification. So natural is 
the superstition which takes fright at severe disease which is "unknown"; and 
which also loses half its horror of the same disease, when the knife of the ana- 
tomist has fixed its locality, even though this do not diminish its danger; — a 
tacit recognition of confidence in science and medical skill. 

In the epidemic which occurred at Schlestat and at Strasburg in 1841, 
(and of this last there is an excellent history by M. Forget, Professeur de 
Clinique, &c, at Strasburg, in the Gazette Medicate de Paris for 1842,) no 
account is made of spots, excepting of an herpetic eruption about the mouth 
and labia pudendi. There is no eruption spoken of in the epidemic at Ver- 
sailles, at Avignon, or at Nancy — nor, in so far as I am informed, in the epi- 
demics in Ireland. 

P. S.— Worcester, April 26th 1849 :— 

With the facts at present before me, I have attempted only to make out the 
pathology of this epidemic. The consideration of its proper treatment, or 
only of the effect of the treatment it has had, would require much more exten- 
sive and careful investigation. I will only add, at present, a fact related to 
me two days since, by Dr. Bawson, of Grafton, who has had twelve cases of 
the epidemic in his own practice in Sutton, and who informs me that he de- 
signs to publish their history. Of the twelve, he lost only the first two. He 
depended mostly upon bleeding and purging — not hesitating to bleed even in 
the cold stage. He relates, particularly, the case of one patient whom he found 
cold, with a small pulse, and whom he bled at once, to the amount of a quart, 



1849.] Parkman, Extracts from Soc. for Med. Improvement. 41 

the skin becoming warm, and the pulse bounding while the blood flowed. The 
patient was much relieved after the loss of blood, as they all were. The head- 
ache being very severe, two or three days after, Dr. Rawson bled him another 
quart with relief. The man got well. 

April 23d Etlierization in Childbirth. — Dr. Channing read the following 
cases : — 

Protracted Labour — Instrumental — Sulphuric Ether — Chloroform.- — Mrs, 

, aged twenty-three, first labour, began March 9th, 1849, at about 1A.M. 

J was called to her in the country, between 3 and 4 A. M. Labour was present ; 
contractions moderate; os uteri somewhat dilated; strength good; cheerful. I 
returned to town between eight and nine, and went again at noon. Some pro- 
gress, but no indications of delivery; os uteri not sufficiently dilated to settle 
what was the presentation; pains moderate. I remained the night, and left 
again for town in the morning. On my return I found the contractions stronger, 
suffering greater; and found the presentation to be face to right acetabulum; 
orbitar processes of the frontal bone distinctly and easily felt beneath the brim ; 
cranium closely fixed in the pelvis, and no impression whatever made by the 
strong contractions now present; the suffering was great, and it was attempted 
to relieve it by inhalation of sulphuric ether. Very little relief came from a 
fair trial, and chloroform was substituted for it. This very soon produced rest, 
quiet sleep, easy respiration ; the pulse, temperature, and complexion, remain- 
ing perfectly natural. In the latter part of the day, it being obvious that no 
benefit was to be looked for from the natural efforts, which continued as strong 
as ever, the forceps were applied. No progress was made, though all safe force 
was used. It being clear that the safety of the mother depended on speedy 
delivery, the forceps were removed and craniotomy done, and the child de- 
livered. These efforts with instruments were made during unconsciousness 
from chloroform; the patient did not know when the child was born. Not the 
smallest injury was done, nor did the least morbid process occur in the puer- 
peral state. Some anxiety was felt, as a lady in the neighbourhood, who was 
delivered about the same time, was seized with puerperal peritonitis which was 
speedily fatal. 

Natural Labour — Laceration of Perineum without Etherization. — Mrs. • ? 

aged twenty-six, first labour, was taken with labour March 15th, very early in 
the morning. I was desired to see her about six A. M. I found her up, ap- 
parently in usual health, with occasional uterine contraction, which was so 
slight as hardly to attract attention. I was on my way to visit the above case, 
and left for her residence. I returned between eight and nine, and called again 
on my city patient. She was quite as comfortable as in the morning, and I 
left, to be called when needed. This was between 10 and 11 A. M. Upon 
reaching the house I found the child was born, and after a manner so easy that 
it was hardly thought necessary to send for aid. The infant had not been 
separated from the mother; this was now done, and the placenta soon followed- 
Upon examining the perineum, I ascertained that it was entirely torn through 
to the edge of the sphincter ani or termination of the rectum. The rent was 
felt to be as smooth as if made with a knife. The getting up was good, and 
union of the wound took place. I have made this record of this case because 
of the late discussion in the Society, of the question whether support of the 
perineum is ever necessary, and, farther, because of an assertion of a member 
of the London Westminster Medical Society, at a late meeting, who stated 



42 Parkman, Extracts from Soc. for Med. Improvement. [July 

that chloroform produced rupture of the perineum. In my case no physician 
was present during delivery, the nurse gave no support, and no chloroform was 
employed. I do not remember to have met with so entire a laceration of the 
part as in this instance. 

Protracted Labour — Instrumental — Laceration of Perineum without Ether- 
ization. — Mrs. , aged about thirty, first labour, March 15th. I was called 

out of town to see this case in consultation, at the close of the second day from 
its beginning. The forehead was towards the right acetabulum., the anterior 
fontanelle presenting, and the head firmly impacted in the pelvis. The con- 
tractions were strong, and suffering much ; but it was thought unnecessary to 
deliver, and I left, to be called at any moment when the physicians in attend- 
ance judged farther assistance necessary. I was called about 8 A. M. following, 
sixteen hours after my first visit. It was now obvious that the time had come 
for delivery, and the child was delivered by the forceps. It was born alive. 
Etherization was neither desired nor attempted. Every precaution was taken 
to prevent injury to the perineum, but very extensive laceration took place, 
which was long in healing. The pressure on the bladder had deprived it of 
power to empty itself, and the catheter was required for some time. The child 
was born alive, and the woman ultimately did well. 

Painful Labour — Instrumental — Chloric Ether. — Mrs. , about twenty- 
four, first labour, was taken ill early on the morning of March 29th. The 
uterine action was rapidly and most strongly developed, and the resistance of 
the unprepared organs to the passage of the child made the sufferings of the 
patient truly agonizing. I was desired to see her in consultation at about 1 
P. M. Her medical attendant said to me, " I have sent for you to deliver this 
woman, for I feel sure that her life is endangered by her labour." I requested 
that chloric ether might be sent for, and proceeded to examine the patient. I 
found the face to the symphysis pubis, the anterior fontanelle presenting ex- 
actly in the centre of the vagina. The fontanelle was unusually large, and 
for a moment I thought the delay of delivery might be owing to dropsy of the 
cranium, and especially did I think some such cause must exist when I wit- 
nessed the strength of the uterine contractions, and the total want of impres- 
sion upon the head. This had reached the pelvic outlet, and one would have 
expected delivery at any moment: this state of things, however, had existed 
many hours. The diagnosis was determined by examining the sutures. 
These were in their usual contact, or overlapping, making it clear that the 
great size of the fontanelle was the result of imperfect ossification. 

As soon as the ether was obtained, the instrument was applied, and inhala- 
tion began immediately after. Extracting effort was soon made, and the child 
delivered with much ease. It cried at once, and lustily. Upon examination, 
the anterior fontanelle was found to be as described j both feet clubbed, and a 
large spina bifida. The child died a day or two after; the patient did perfect- 
ly well. Not a morbid occurrence disturbed her rapid convalescence. There 
was not the smallest local lesion of any kind. The perineum was not in the 
slightest degree injured. We have, in succession, three cases of certainly not 
common positions of the foetal cranium during labour. All were instrumental. 
In two etherization was practiced; in two labour was much protracted; in one 
delivery was accomplished in a few hours after labour began. The result was 
wholly satisfactory. I was glad to find that early resort to instrumental de- 
livery in one case above has the sanction of Prof. Simpson's high authority. 
He suggests that cases occur in which delay is lost time; not only so, that the 



1849.] Parkman, Extracts from Soc. for Med, Improvement. 43 

chances to both mother and child may be greatly diminished by the continu- 
ance of protracted and ineffectual labour. 

Arm Presentation — Chloric Ether. — Mrs. , about thirty, sixth labour, 

April 15th, about 1 A. M. ; physician called at 5 A. M. ; arm protruding from 
external organs ; water had come away some time before. I saw this patient 
about 6 A. M. She is strong, plethoric, in full health ; she told me I delivered 
her with the forceps five years ago. It was agreed to turn, and that chloric 
ether should be inhaled — strength, 35 per cent, chloroform. It produced the 
ordinary effects of chloroform about as soon as does chloroform itself. There 
was heavy profound sleep ; noisy stertor, or snoring ; perfect insensibility, and 
as perfect unconsciousness. Turning was accomplished with entire ease. The 
child was born alive, but did not long survive. Convalescence was rapid and 
uninterrupted. 

Convulsions — Chloroform. , aged fifteen, first labour, April 16th, at 

about 1 A. M. Began with vomiting. Physician found her in violent con- 
vulsions; was very fleshy, and in perfect health; no error of diet; full blood- 
letting, about 5xxx; leeches to temple; terebinthinate enemata, cold to head. 
I was called to see her at about 1 P. M. Found her very ill; face pale; livid; 
respiration heavy, laborious; pulse from 192 to 200 in the minute, small, 
sharp ; convulsions violent ; os uteri dilatable ; slightly dilated ; show ; head 
presenting. I advised chloroform; it was at once inhaled, and this very 
thoroughly; it checked the convulsions, so that no more occurred. The 
labour proceeded. At about 3 P. M. she recognized her mother, and gave 
other evidence of consciousness. I left her, soon after, doing perfectly well. 
This patient was carefully watched, and whenever a convulsion was threatened, 
which was denoted always by wide-staring, fixed eyes, chloroform was imme- 
diately inhaled. In this instance consciousness returned sooner than in any 
case which has come before me. 

Natural Labour — Chloric Ether — Chloroform. — Mrs. — j — , aged twenty- 
six; first, labour April 17th, about 2 P M. In this case etherization was 
practiced simply to relieve intense suffering. Chloric ether ; its effects were 
disagreeable, and very slight in regard to relief. Chloroform was substituted, 
and with entire relief. Labour was finished during unconsciousness and in- 
sensibility, without complaint, and entirely successful both with regard to 
mother and child. 

Natural Labour — Chloric Ether. — Mrs. , aged twenty-four, first labour 

April 22d. I was called at 2 A. M., about four hours since beginning of la- 
bour. Very soon contractions grew strong, vehement, and the suffering was 
declared to be intolerable. Between three and four, inhalation of chloric ether, 
imperfect, effects slight. At length, however, the suffering was such that fair, 
full inspirations were practiced. Almost at once entire etherization occurred. 
It precisely resembled that which follows chloroform, as did that in the case 
of arm presentation; was as deep, and as grateful. The child was born alive, 
during entire unconsciousness. Weight 9ib. I left the mother perfectly well. 

Placenta Prdevia — Chloric Ether — Chloroform. — Mrs. — , aged about 24, 
fourth labor. In one only, the second, of the three preceding, was the foetus 
carried to the full time: all born dead. Called about 5 A. M., Thursday, 
April 19th, on account of flowing. Found her vomiting, and learned she 



44 Parkman, Extracts from Soc. for Med. Improvement. [July 

liad vomited for some time. Face pale, (edematous : expression anxious, 
heavy. Labour began in night, no sleep ; deep, heavy gaping, such as ac- 
companies exhaustion; says stomach feels cold, and can bear nothing in it; 
keeps hand to chest, and complains of distress and sinking about praecordia. 
Pulse rapid, neither full nor strong. Flow very slight, requiring a napkin 
now and then ; os uteri high, looking towards hollow of sacrum ; cervix about 
half done away with, being of the length of the time of pregnancy, be- 
tween the 7th and 8th month; os uteri scarcely admitting finger, round, firm. 
Very little flow accompanied or followed examination ; much distress during 
uterine contractions, which were regular; and some pain at the time low in 
the back. I left, directing positive rest. 

About 9 A. M. Things very much as at first call. No more hemorrhage 
than then. Rather stronger contractions, and more suffering; vomiting con- 
tinues. Sitting up on the bed with the legs bent under her, a position, as I 
was informed, she assumed in her former labours. Is restless, changing place 
often. For the sinking at stomach directed a mixture of gin, warm water, 
and sugar, in teaspoonful quantities; and for the great pain and suffering 
during contractions, inhalation of chloric ether. The strength was 35 per 
cent, of chloroform to 4 of water, and the rest strong alcohol. It was poured 
upon a handkerchief and inhaled as felt to be needed. Its effect was to di- 
minish pain, to procure rest, without sleep. It left consciousness unimpaired. 
I advised her to lie down, which she declined to do, the sitting position being 
the most agreeable. Os uteri remains as at first examination. I now left to 
be called if occasion required. 

About 12, noon. Less hemorrhage than at any time. Appearance less 
satisfactory, face without colour; distressed; speaks feebly; gaping deeper and 
more frequent, manifesting increased exhaustion. Pulse as at first visit; con- 
tractions stronger. Has inhaled chloric ether occasionally, with slight dimi- 
nution of suffering; no sleep. Is sitting as when last seen. Hemorrhage 
very suddenly and profusely declared itself. Examination showed os uteri 
unchanged, and the placenta completely over it. It was obvious that this 
state of things demanded immediate attention. I passed my left hand into 
the vagina, and reached the os uteri. It allowed two fingers only partially to 
enter it. Hemorrhage rapidly increased, and was more violent than is remem- 
bered in any case before met with. It was obvious that it could not be borne 
longer without fatal issue. The hand could not pass the os uteri but with a force 
which no circumstance could justify. I recollected at once the effect of chlo- 
roform in similar cases, in which, as in this, the suffering was extreme, he- 
morrhage excessive, and the danger imminent. About a teaspoonful was 
poured upon a folded handkerchief, and held toward the face. To be sure of 
the quantity, I poured it out myself, the nurse holding the handkerchief. The 
effects were rest, less expression of suffering, and questionless increased dilata- 
bility. The hemorrhage continued unabated. Inhalation was stopped ; the 
hand was passed steadily, but without violence, between the placenta and 
womb, the membranes reached and ruptured, a leg readily reached, brought 
down with perfect ease, and the child delivered : the placenta followed imme- 
diately, and before division of the cord had been made. The patient was 
perfectly conscious of what happened, asked if the child was alive, and ex. 
pressed the ordinary interest in it. Etherization was not perfect, but it had 
accomplished all the purposes designed in its use. The womb contracted at 
once and perfectly. I applied my hand over it to secure contraction and to 
prevent further hemorrhage. Complaint was made of the pain my pressure 
produced. A thick compress was placed upon the uterine tumour, and a 



1849.] Parkman, Extracts from Soc. for Med. Improvement. 45 

swathe tightly drawn kept it in its place. Slight hemorrhage occurred after 
the delivery. The pulse soon after was not to he felt. Stimulants were at 
once given. Infusion of ergot with the powder freely exhibited. Some re- 
action now occurred. The mind was throughout perfect. There was no 
sighing, nor jactitation. She spoke of her state, of being better, and of 
being worse. Reaction was of short continuance, sinking came on, and in 
about two hours after delivery, and by a gradual failure, death took place. 

Cases like the above are now and then met with. I remember two which 
occurred some years ago, which nearly resembled it. One, in which sudden 
hemorrhage took place in a latter month of pregnancy. It was very profuse. 
A week passed, and, on a Sunday morning, a still more violent flow happened. 
The physician was called. He found the placenta over the mouth of the 
womb, and urgent hemorrhage. I was asked to see this patient. I found 
her in extreme danger, and it was agreed that delivery should be attempted. 
This was successfully done. Reaction followed most threatening sinking. It 
continued about an hour, when, after very little further loss of blood, sinking 
returned, and speedy death. In another case, death occurred sooner after de- 
livery, but in this hemorrhage continued from Thursday noon to Sunday 
night, when, on account of threatened death, delivery was accomplished. 
There was not a moment before this in which the attending physician or my- 
self believed that forced delivery would have been justifiable or even possible. 
These are the only cases of death after placental presentation that have come 
under my own observation, and in these I was a consulted physician. A case 
of great interest was reported lately at a meeting of this Society. The pla- 
centa presented directly over the os uteri. Profuse flow came on. It was 
obvious to the physicians in attendance that death would soon occur unless 
delivery was accomplished. This was done by turning. The womb con- 
tracted well. Fair reaction came on, and everything promised well. But in 
about an hour after delivery, secondary hemorrhage occurred, I believe an 
exceedingly rare accident after placenta prasvia, and which was almost imme- 
diately fatal. Etherization was not employed in either of these cases. I have 
met with two cases of placenta prsevia, in which chloroform was inhaled with 
entire success. In one of these, not that in my first communication, I found 
the patient in a state which seemed utterly hopeless. She was without pulse, 
the skin was cold and exsanguious. I told the medical attendant that I thought 
it best to accomplish delivery when it could be done, and that chloroform 
would prevent suffering, and facilitate dilatation. It was agreed to try it. 
Perfect etherization was induced — the child was turned and delivered. The 
placenta at once followed. Reaction occurred, and the effects of hemorrhage 
were perfectly recovered from. I have never met with a case so wholly un- 
promising in which success was more perfect. The case in my first commu- 
nication, of placenta praevia, was as hopeless as this. See a third, of the same 
character, at p. 297 of my Treatise on Etherization in child-birth. 

In the case just reported, the cause of existing symptoms was a matter of 
much thought. It seemed that symptoms so declared of grave sinking ; and 
No. XXXV.— July ; 1849. 4 



46 Parkman, Extracts from Soc. for Med. Improvement. [July 

depression of power could not depend upon the visible hemorrhage. They 
had some of them existed before labor began. The labor itself was prema- 
ture : vomiting had existed some time, and ushered it in. The gaping was 
very striking, and, together with the blanched face and lips, the restlessness 
and general malaise, was calculated to produce uneasiness, and to suggest 
grave lesion as the cause. Internal hemorrhage became thus a matter for 
thought. I recollected a case to which I was called in consultation, but which 
was fatal before I reached the address, in which internal hemorrhage was the 
cause of death, and in which the blood was contained between the placenta 
and womb, without a drop appearing externally. Examination, after death, 
disclosed precisely this state of things. But in the above case there was ex- 
ternal hemorrhage, slight, indeed, and constantly watched. The abdomen was 
very carefully examined by pressure, and the womb always found well con- 
tracted. The os uteri was open, which was not at all the case in the above 
instance referred to, and there was fair uterine contraction. Nay, this was 
most striking at my latest visit, at noon, and then the hemorrhage was least. 

The membranes were entire, and a free channel existed between them and 
the womb, for any blood which might escape from vessels, left open by the 
separation of the placenta. The position of the patient, erect, as it regards 
the trunk, favoured the freest escape of blood through the open os uteri. 
Blood was actually flowing through it at my first visit, and did not entirely 
cease to flow. 

The use of chloric ether was very beneficial in this case. It did not pro- 
duce complete etherization, to be sure, for neither was sensibility nor conscious- 
ness, in any sense, abolished. Its effects were quiet, diminished suffering, and 
relief from the indescribable distress of which the patient was almost so con- 
stantly conscious. For the most part, she managed inhalation herself, using 
it when she desired its relief. Chloroform was substituted for chloric ether 
because of the pressing demand for its important agencies. Hemorrhage, as 
so frequently happens in these cases, at last occurred suddenly and violently, 
and at once threatened a fatal issue by its quantity j and how much was the 
danger added to by the exhausted state of the patient when labour begun. 
The use of chloroform was short. It diminished suffering, and promoted 
dilatability. These were the effects of all others to be desired. What of 
strength remained was not exhausted by suffering, and in delivery the pros- 
pect of safety only could be found. The womb contracted promptly, and 
retained its own contraction. The blood coagulated as firmly as I have found 
it to do in any case of hemorrhage. The respiratory function was carefully 
watched, and was steadily performed. Death occurred under circumstances 
which always accompany fatal hemorrhage, and about the characters of which 
no observing physician can have any doubt. 



1849.] Warren, Ether in Liihotrity and Lithotomy. 47 



Art. III. — Liihotrity and Lithotomy, with the use of Ether in those operations. 
By J. Mason Warren, M. D. 

When ether was first introduced into use in surgical operations, it was 
thought by many that this substance would be found wholly inapplicable to 
the destruction of the stone in the bladder by crushing instruments. The 
objections raised were principally these: 1st. That, in order to preserve the 
integrity of the mucous membrane of the bladder, it was necessary that the 
patient should be possessed of his full consciousness, so as to give the surgeon 
warning when the coats of the organ were included in the instrument. 2d. 
That the operation might be pursued to a dangerous extent, unless information 
was given by the patient's feelings and powers of endurance, when it was pro- 
per to desist. 

Such fears, as well as others which have been urged under similar circum- 
stances, have, as will be shown by the following cases, proved fallacious. Not 
having observed any account of the application of ether to the performance 
of lithotrity, among the almost innumerable uses to which it has been applied, 
I have been led to bring together these instances and present them to the public. 
From these records it would appear, that the facility thus afforded is as great 
as in any class of surgical operations. 

In one or two of these instances, from the great irritability of the bladder 
and urethra, as well as from the extreme hardness of the stone (which required 
a number of operations), it would have been necessary to relinquish the idea 
of employing lithotrity without the assistance of ether. In those where the 
ether was not made use of, it will be found that other points of interest ren- 
dered their introduction advisable. The case of lithotomy is instructive, both 
on account of the manner of formation of the stone, and the great facility 
afforded by the ether in the exploration and operation. 

But few cases are required to establish the fact, that by the use of ether 
lithotrity will be much simplified, and a resort to it frequently made in in- 
stances till now rejected. 

Case I. — J. W , forty years of age,*had for a year or two been troubled 

with difficulty in passing water, attended with extreme irritability of the ure- 
thra, and from the latter cause had not been able to submit to an examination 
of the bladder by means of the catheter. At length, the distress being very 
severe, and the demand for an operation imperative, a catheter was introduced 
by his physician, and a calculus at once detected. The suffering from the 
introduction of the instrument was so agonizing, that he determined to submit 
to no further exploration, but requested Dr. J. C. Warren to visit him, and 
perform the operation of lithotomy. 

After some conversation he was induced to take ether and undergo a second 
examination, which was done with so little pain and knowledge to himself, that 
he was persuaded to submit to lithotrity, which was performed by me in July, 
1847. The patient being under the influence of ether, the stone was caught 



48 Warren, Ether in Lithotrity and Lithotomy. [July 

once or twice, and crushed without difficulty, causing the discharge of a number 
of fragments in the course of a few days. 

At the end of a month the same operation was repeated, by which the entire 
destruction of the stone was completed. He was immediately afterwards 
enabled to resume the practice of his profession, which he continued a year. 
At the expiration of this time he was seized with the symptoms detailed in 
the following letter from his physician, Dr. A. L. Peirson, of Salem, where he 
resided and died, after a few days' confinement, on the morning of June 5th, 
1848. 

" J. W , held court in Boston week before last. He had hematuria, 

and his general health suffered so much, that he was prompted to adjourn the 
court, but persevered till its term was finished, and came home on Wednesday, 
May 25th. His physician, Dr. Holyoke, saw him, and administered an in- 
fusion of uva ursi; and on Saturday, feeling as well as usual, he made arrange- 
ments for holding court at Martha's Vineyard, the ensuing week. He dined 
heartily on Saturday, and indulged imprudently at dessert in nuts and raisins. 
He probably took no wine, as he did not accustom himself so to do. On Sa- 
turday night he had a severe chill, with violent pain in the right hypochondriac 
and iliac regions. These symptoms persisted, with some abatement, till Friday 
morning, June 2d, when I first saw him. He then had much nervous excite- 
ment, a pulse very rapid and rather feeble, tjanpanitis, and abdominal tender- 
ness, with acute soreness where the pain had been, and was hollow-eyed and 
anxious-looking. He took chloroform with great satisfaction, a moderate opiate, 
and a mild purge. 

"My hopes and expectations were, that his difficulty was like what he often 
had experienced before from irritation, and which had always subsided after 
the employment of mild measures. I awaited the action of the alimentary 
canal, which I trusted would prove to have been the focus of irritation, causing 
sympathetic trouble in the urinary apparatus. He had one full evacuation, 
principally of fecal matter, with no change of symptoms that was satisfactory. 
The tympanitis, tenderness, and frequency of the pulse diminished, and his 
pain wholly left him on Saturday, June 3d. His weak pulse, haggard look, 
and the failure of relief from the laxative, gave Dr. H. and myself the greatest 
alarm. He gradually sunk, and died at four o'clock on Monday morning, 
after twenty-four hours of mild delirium. 

"The death of this gentleman was apparently caused by disorganization of 
the right kidney. It contained a small calculus in its concavity. A smaller 
one was found in the left kidney, being the only morbid appearance discovered 
in that organ. I send you both calculi. There was infiltration of pus, and 
purulent, sanious, serous fluid into the cellular tissue around the gland. A 
small patch of pure pus covered a spot on the thin edge of the liver. On 
laying open the ureter and infundibulum, which were considerably enlarged, 
a dark, smoky-looking circle, almost entire sphacelation, surrounded each pa- 
pilla. But little of the medullary portion seemed capable of performing its 
function. A quantity of sanious fluid, with hardly a character of urine, was 
found in the kidney. The bladder was perfectly sound, without a mark of 
inflammation, and was of natural size. There was no appearance of calculus, 
and only a few grains of the finest sand, such as he often passed." 

Case II. — Calculus of Oxalate of Lime — Lithotrity under Chloric Ether — 
Purulent Absorption. — The three following cases occurred at the Massachusetts 
General Hospital, from the records of which institution the minutes are in 
part derived. 



1849.] "Warren, Ether in Liihotrity and Lithotomy. 49 

Nov. 24$, 1847. John Kelly, 20 years of age, had for the past ten years 
been troubled with difficulty about the urinary organs, manifested by occa- 
sional pain in passing water, pains in the loins on stooping, or making any 
exertions. Eighteen months since he contracted a chancre on the frsenum, 
which was followed by a bubo in the groin. He recovered from these in 
about six months. 

Nine weeks ago, after, exposure to wet and cold, he found much difficulty 
in passing his water, the stream being small, tortuous, and attended with a 
smarting pain at the end of the penis. Since the present disease he has had 
a serous discharge, which at times is mixed with blood. In this state he en- 
tered the hospital, and on examination the urethra was found to be so con- 
tracted, as hardly to admit the smallest sized bougie. 

The stricture was gradually dilated by the introduction of bougies increas- 
ing in size, but notwithstanding the enlarged passage, and the free egress of 
the urine, the patient still complained of much pain at the extremity of the 
glans penis, and was obliged to pass his water ten or twelve times in the 
twenty-four hours. 

From these symptoms I suspected the existence of some foreign substance 
in the bladder. The urethra being extremely sensitive, and the patient mak- 
ing a great outcry at any attempt to sound him, he was placed under the in- 
fluence of chloric ether, and a curved sound introduced, by which I at once 
detected a stone. 

Having waited a few days to allow the bladder to recover from the effects 
of sounding, on March 11th, the operation of lithotrity was performed. The 
patient was first etherized with the chloric ether, so that the muscular system 
was in a complete state of relaxation : half a pint of warm water was now 
injected into the bladder. A small lithotrite was then introduced, and the 
stone at once seized, but it proved to be too hard. This instrument was with- 
drawn, and a larger and more powerful one substituted ; by which the stone, 
having been caught, was broken with repeated strokes from the hammer. 
Some difficulty was found, on withdrawing the instrument, in passing the seat 
of the stricture, on account of its jaws being clogged with sand, and therefore 
imperfectly closed. The patient was entirely insensible during the whole ope- 
ration, and not the slightest contraction of the bladder impeded the necessary 
manipulation. 

The continuation of this history, as derived from the same records, is in 
substance as follows : — 

An hour after the operation, the patient passed considerable urine with 
several pieces of gravel, about one-half the size of a pea, and some fine sand, 
in all nearly half a teaspoonful. The urine contained a little blood, which 
was apparently from the urethra. 

At 3 P. M. he had a severe rigor, lasting fifteen minutes ; passed urine once 
since the last report, some gravel came away with it. 5 P. M. some small 
pieces of the gravel which had lodged in the urethra, were removed with the 
forceps. The bladder was washed out with cold water; cold compresses were 
applied to the urethra, from which a little blood had been oozing. 

At 8 P. M. he complained of headache, pulse full and hard. He was bled 
to twelve ounces with much relief. 

At 11 P. M. pulse 120, soft; was sleeping quietly. 

March 12th. Very comfortable; pulse 96. Some small fragments of cal- 
culi came away. P. M. pulse 140, some headache, no tenderness of bowels, 
and but little irritability of urethra ; passage of urine free. 

lZth. He urinates freely, but has a little tenesmus on doing so. The 



50 Warren, Ether in Lithotrity and Lithotomy. [July 

smarting and pain are very slight j very little detritus in the urine. Twelve 
leeches to perinseum, with a warm bath and enema, were ordered. 

In P. M. had a chill; now complains of malaise, pain in the shoulders, back 
of the neck, and weakness of the right arm. The countenance is better than 
yesterday ; pulse 130. 

14th. There is pain in the shoulders, with some superficial tendency. The 
urine is natural; but the passage of it is attended with some pain. There is 
no appetite. 

On the 15th, another fragment of the calculus was removed from the urethra 
by the forceps. 

16th. Pulse 120. The countenance is somewhat depressed. He complains 
of great pain in the right shoulder and arm, as well as between the shoulders; 
also in loins and left side of back. He also has tenderness along the course 
of the left carotid artery ; countenance depressed ; bowels free. He has no 
trouble in passing urine, and but little soreness of the urethra. 

17th. His looks are more depressed than yesterday; pulse 120; pains 
about the shoulder and neck continue the same. 8 P. M. Since noon the 
pulse has risen ; it is now 200, perfectly distinct and regular, but weak. The 
countenance is anxious, the voice feeble. He complains of great pain in the 
back and shoulders, and of distress at the epigastrium. He was allowed to 
take a small quantity of wine every half hour. 

1Mb. He is much the same; pulse 212, full, and stronger than yesterday. 

19th. Countenance is better, pulse 180, stronger and fuller; skin quite 
warm and moist; tongue clear, thirst slight; relishes broth; no dejection; 
considerable flatus in the intestines. In the afternoon, had pain in his neck 
and shoulders, also in his right foot. On examination a diffused swelling is 
discovered over the metatarsal bone of the little toe. A red patch had also 
formed over the sternal extremity of the left clavicle. Pulse 204, "is sweat- 
ing profusely; continue wine. 

20th. Rather more feeble than yesterday. A plaster of the cerate of can- 
tharides was applied to the inside of the right thigh. Pulse 210. He passes 
water by his own account, with more ease than he has done for two years. 
He continues to complain of great pain in his back and left shoulder, and of 
great distress about his heart. 

21st. The pulse was 200. 

22d. I opened an abscess over the tarso-metatarsal articulation of the left 
little toe, and found the bone denuded. 

23d Pulse 190. From this period the frequency of the pulse began to 
diminish, and he went on slowly improving until April 2d, when he was seized 
during the afternoon with a severe pain about the left clavicle and upper part 
of the left side of the chest. Great swelling had taken place in the part 
since noon, so as almost to bury the clavicle. It also extended up the neck 
of that side. The integuments over the clavicle were red and cedematous. 
He had great difficulty of breathing, and the pressure on the trachea almost 
produced suffocation. I immediately made a dissection down to the clavicle, 
but no pus could be discovered. The bone itself was evidently enlarged, and 
my impression from the symptoms was, that pus was forming in its interior. 

The incision afforded him some ease by the abstraction of blood, and giving 
relief to the extreme tension of the surrounding integuments. A poultice 
was directed to be applied over the wound, and an opiate to be administered. 

The pain was less on the following day. On the 21st of April, the swelling 
about the clavicle had nearly disappeared, but the inner third of the bone was 
felt to be enlarged. 

From this period he slowly recovered, and left the hospital free of complaint. 



1849.] Warren, Ether in Liihotrity and Lithotomy. 51 

Remarks. — The operation in this case was rapidly done, with no violence to 
the bladder, as shown by the symptoms at the time and afterwards, none of 
which had reference to that organ. The stone was small, and not being aware 
of the hardness of it, I thought it would yield to a small instrument. The 
power of this not proving sufficient, it was withdrawn, and another introduced ; 
which, however, was so constructed as not to clear itself of the detritus or 
sand made by the crushing process. From this reason the instrument, which 
passed the obstruction, caused by the stricture, with ease, on its introduction, 
was arrested there on its withdrawal, from the jaws being imperfectly closed, 
and some force was required, though not amounting to violence. 

It will be perceived that the fragments of stone all came away within a week 
of the operation. In three days after its performance, he began to have pain 
in his shoulders, after which all the symptoms denoting purulent absorption 
manifested themselves. The pulse, for eight or nine days after the 17th, re- 
mained constantly very rapid, ranging from 190 to 212. There seemed to be 
a tendency to the formation of pus in different parts of the body ; it was found 
about the metatarsal bone in the foot, and was presumed to exist in the cla- 
vicle ; from the latter it was probably absorbed without making any appear- 
ance outwardly. 

This case will evidently come under the category of those placed by Vel- 
peau and Civiale as instances of purulent absorption, sometimes caused by the 
simple introduction of a catheter, but more frequently in lithotrity by the irri- 
tation of fragments lodged in the urethra, and about the neck of the bladder. 

The stone was analyzed by Dr. Bacon, one of our most distinguished che- 
mists, who gave me the following note of its constituents : " It consists chiefly 
of oxalate of lime ; it also contains considerable uric acid, and a small quan- 
tity of carbonate of lime. The concentric layers are very numerous. In 
some fragments under the microscope, I counted from ten to twenty, or even 
more, layers in the space of one-fiftieth of an inch. The radiated structure 
is also seen under the same circumstances, the radii being still finer than the 
layers which cross them at right angles." 

Case III. — In the two following cases of vesico-vaginal fistula a calculus 
formed, either from a phosphatic deposition upon the catheter becoming de- 
tached, (thus acting as a nucleus,) or from the collection of calcareous matter 
about the edge of the fistulous opening. 

S. S , 27 years of age, entered the hospital April 3d, 1848, and gave 

the following account of herself. She had been confined three months pre- 
vious ; the child was large and had been dead for some time. After having 
been in labour thirty hours, during which time the pains were severe, the 
forceps were used, but without success j she was told that they had slipped 
from the head of the child. About ten hours after the trial of the forceps 
she was delivered without assistance. The deliverance took place on Monday 
at noon; she had then passed no urine for several hours, and none came from 
her until Tuesday afternoon, when a catheter was used, and about three pints 
drawn off. From that time until March 31st urine ran from the vagina con- 
stantly ; on this day, without known cause, the urine was retained ; her phy- 



52 Warren, Ether in Lithotrity and Lithotomy. [July 

sician could find none with a catheter, and none flowed until the next day, 
when " something gave way, and some thick white matter was discharged," 
since when the urine has flowed as before. 

A large discharge of very offensive matter from the vagina continued for 
several weeks after labor. She has not menstruated since confinement, but 
every month has severe pain in the back, and bearing down sensation in the 
pelvis. At such times she thinks the urine is more abundant. 

April 3d. The catheter being introduced, about an ounce of very thick 
muco-purulent matter came through it. The instrument was directed to be 
left in the bladder. On examination, the vagina was found to be obliterated 
to within half an inch of the external organs; at the lower part of this ob- 
struction was an opening, through which the urine escaped. 

7th. The patient having been placed under the influence of chloric ether, 
the callous edges of the fistulous opening were thoroughly cauterized with a 
prepared stick of the potassa cum calce. She suffered no pain from the appli- 
cation. The subsequent position was upon her side, having in the bladder a 
large catheter provided with a shield, and constructed for the purpose. 

By the 17th of April the fistulous opening had contracted, the urine con- 
tinued to pass by the canula. The edges of the fistula were touched occasion- 
ally with the nitrate of silver, and in the course of another month it was com- 
pletely obliterated. 

On May 26th, the patient having complained frequently for a week before 
of pain in the back and loins, with difficulty of urinating, I passed a catheter, 
and immediately detected a calculus. The lithontriptic instrument was intro- 
duced, and the stone at once caught and crushed. On the following day all 
the fragments had passed in the urine. 

This patient is now, April, 1849, in the enjoyment of good health, except 
at the period of menstruation, when she has a severe attack of pain in the 
hips and abdomen, attended with hysterical symptoms lasting usually four or 
five days, and requiring the use of leeches, purgatives, warm baths, and other 
debilitating remedies before the system is relieved. I have once or twice ex- 
amined the uterus by the rectum at these periods, but found no perceptible 
fulness or projection of this organ into the bowel.* A question arises how 
these symptoms are ultimately to terminate ; a point to which I shall have 
occasion to advert in the following case. 

Case IV. — Vesico-vaginal Fistula — Phosphatic Calculus. — A. L , set. 

32, entered the hospital March 9th, 1848. Fourteen weeks since she was 
delivered by forceps, after a labour of four days. During this, period she was 
for the greater part of the time insensible from the effects of narcotic sub- 
stances. The child was delivered on Tuesday. 

On the following Thursday there was incontinence of urine, and it flowed 
constantly from the vagina, never passing by the urethra, or collecting in the 
bladder. 

She has not menstruated since her labour, nor has she had. any difficulty at the 
period when the menstrual secretion should appear. There has, however, 

* May XOth — This patient for the last two weeks has been suffering under a paroxysm 
of unusual severity. The pain is so violent as to resist the use of almost any quantity 
of narcotic substances. She has had one or two attacks of vomiting, in which a large 
quantity of blood has been ejected. She makes the most earnest appeals for relief, and 
is willing to submit to any operation by which that point can be attained. From the en- 
tire obliteration of the vagina, and absence of fulness in the rectum, there seems to be no 
spot at which the uterus can be safely reached. 



1849.] Warren, Ether in Litliotrity and Lithotomy. 53 

been much milk in the breasts, but varying in degree ; she has not noticed 
any relation between the quantity secreted and the catamenial period. 

On examination of this patient the external organs were found excoriated 
by the urine, which was constantly dribbling away from her. The vagina was 
somewhat contracted throughout its whole length, but more especially at about 
three inches from the external organs, where there was a very marked con- 
striction. Behind this was a longitudinal slit, with callous edges, on the an- 
terior wall of the vagina, through which water was seen issuing from the 
bladder. A small irregular opening existed at the posterior part of the vagina 
near the situation, or in the place of the os uteri, which had entirely disap- 
peared. 

The patient was thoroughly etherized with chloric ether, as it was found almost 
impossible to make the slightest examination, on account of the extreme sen- 
sibility of the parts. The speculum of liicord was used both for the exami- 
nation and the operation. The edges of the fistula were now cauterized so as 
to produce a slough, with the potassa cum calce, and a catheter introduced. 
This instrument, which had been made for the purpose, was half an inch in 
diameter, five inches long, with a shield an inch from its external orifice. 

The patient suffered but little from the caustic, and no urine passed through 
the fistula for several days. It was touched occasionally with creasote; 
and on the 18th, no urine having passed through the fistula for some time, 
the catheter was omitted, and she was allowed to walk about. 

On the 23d of April, she reported that no urine passed by the vagina. 
When the catheter was first omitted, the water dribbled away from the urethra, 
which from long disuse had apparently lost its power of retention. This 
power, however, was by degrees restored. 

On May 7th an examination was made both by the vagina with a speculum, 
and by the bladder with a catheter. The fistulous opening was hardly per- 
ceptible. In the bladder was found a calculus, apparently about the size of 
that mentioned in the preceding case. Immediately I sent for the lithontriptic 
instrument, with which the stone was easily caught and crushed. On the 
following clay the fragments of the stone came away with the urine. They 
were found to be composed of the phosphate of lime. 

This patient remained in the hospital until the latter part of May, when 
she had the full command over the urine. During the whole of this time 
there was no appearance of the menstrual secretion ; but at stated periods, at 
an interval of four weeks, an increased secretion of milk took place in the 
breasts. 

I have recently seen this woman. She stated, that she had been well since 
she left the hospital. About three months since, nearly a year after her de- 
livery, the catamenial function was restored, and has continued regular since. 
This must have had its exit at the orifice, which took the place of the os uteri, 
and which undoubtedly at the commencement was partially occluded. 

On over distention of the bladder a small quantity of urine was found to 
escape from the vagina. An examination with the speculum, proved the old 
opening to have closed; and that the urine seemed to escape from the same 
fissure in the uterus with the catamenia. 

In connection with this subject it may be interesting to advert to one or 
two other cases of vesico-vaginal fistula in regard to the same particular. For 
I have not been able to find that any author has given the results of his ex- 
perience, as to the probable manner in which the menstrual fluid makes its 



54 Warren, Ether in Liihotrity and Lithotomy. [July 

escape, in cases where the orifice is obstructed by the sloughing and inflamma- 
tion following difficult labours, which has occurred in about one-half of the 
instances under my observation. 

In one case of sloughing of the bladder and occlusion of the os uteri, in 
which I operated a year since by sutures, the fissure was completely cured. 
The menstrual secretion has never been restored. Once in four weeks, at the 
catamenial period, the patient is seized with the most distressing pains in the 
uterine region, attended with sickness and sometimes vomiting. These symp- 
toms continue a week, and cause the utmost distress. I have repeatedly ex- 
amined the supposed seat of the os uteri, to determine if any projection took 
place there at those periods, with the idea of puncturing, but have never had 
any encouragement by the appearance to justify an operation. 

In another woman, where the whole lower half of the bladder was lost by 
sloughing, the same symptoms were manifested. At one of these periods, at 
the distance of a year from their commencement, the pains became violent 
and forcing, as in labour. At this moment a rupture of some part of the 
uterus into the vagina took place, and the patient was, as she states, at once 
deluged with blood, so that long-continued fainting took place, from which she 
was with difficulty recovered. The menstrual function has since gone on 
regularly. 

Although thase remarks may seem irrelevant at the present time, yet if they 
should elicit any information from other sources on this interesting subject, 
they will not be without their good result. 

In regard to the formation of the calculus in these two cases, it cannot be 
attributed to any negligence in the use of the catheter, as it was regularly 
withdrawn and cleansed, once or twice in the twenty-four hours. I should 
rather be disposed to attribute it to the collection of the phosphates, in and 
around the fistulous openings, as we sometimes see after cases of lithotomy. 

Case V. — Cystic Oxide Calculus — Lithotrity. — J. C , aged forty-three? 

of Montgomery County, New York, applied to me in July 1848, and gave 
the following history of his case : Seven years ago he was seized with a vio- 
lent pain in his side, which was attributed by his physician to the passage of 
a calculus through the ureter. Shortly afterwards a calculus, of the size of a 
pea, was voided with his urine. 

He has a number of times since passed calculi ; and on one occasion, after a 
severe paroxysm of pain, says he could tell distinctly the moment when the 
calculus entered the bladder; he arose from his bed immediately and passed 
the stone. 

Three months since, while engaged in ploughing, he felt a pain in his 
bladder, the commencement of the sufferings which have continued to increase 
until the present time. He is obliged to pass his water frequently; it is occa- 
sionally bloody. He cannot ride in a carriage without extreme pain ; in walking, 
he is compelled to move very slowly. 

I sounded the patient with a small lithotrite, and at once detected a calculus. 
This being embraced by the jaws of the instrument, gave a measurement on 
the scale of an inch and a half. Some irritation of the bladder followed this 



1849.] Warren, Ether in Lithotrity and Lithotomy. 55 

examination, which was made after the fatigue and excitement of a long jour- 
ney, and it was necessary to keep him quiet for some days, and use remedies, 
before any operation could be performed. 

On July 13th, the bladder being injected with half a pint of warm rain 
water, the stone was immediately seized by the crushing instrument, and broken 
by means of the screw without much difficulty. 

15^. He had suffered no inconvenience from the operation, and in fact feels 
relieved. A quantity of sand and fragments of stone have passed with the 
urine. 

The operation was repeated on the 18th, 23d, 26th, 29th, and Aug. 2d. 
After each operation the patient passed a number of fragments, and once or 
twice it was necessary to remove by the forceps portions which had become 
lodged in the fossa navicularis, and were too large to pass easily the external 
orifice of the urethra. On Aug. 3d, a fragment, which had been engaged in 
this way, and which it was found impossible to extract entire, was seized by 
a powerful pair of dressing forceps, crushed, and thus extracted piecemeal. 

On the 9th he returned home well, and on the 25th I received from him a 
letter, in which he stated that he had experienced no difficulty in passing his 
water, and was otherwise in good health. 

Dr. Bacon kindly made an analysis of the stone, which is contained in the 
following note : — 

" The calculus of which you sent me fragments yesterday for analysis, proves 
to be of a rare and interesting kind. It is composed of cystine, or cystic oxide. 

"The yellow portions consist of cystine in a state of purity, with the exception 
of a trace of phosphate of lime. In the white friable parts, which appear to 
be interspersed in the yellow masses without forming regular layers, the cystine 
is mixed with much phosphate of lime and a little triple phosphate. 

" Your specimens agree pretty closely in physical characters with the descrip- 
tion given by authors of this very uncommon form of calculus. " 

Case VI. — Oxalate of Lime Calculus — Lithotrity. — P. C , fifteen years 

of age, applied to me in -Oct. 1848, with symptoms of great irritability of 
the bladder, such as usually accompany the existence of a foreign body in that 
organ. At this period he declined all examination, although I at once warned 
him of the probable nature of the disease. 

In November, nearly a month afterwards, finding that no remedies had any 
effect in relieving his sufferings, he submitted to the operation of sounding, 
and I detected quite a large calculus. 

His mother gave the following history of his case : He had been troubled 
in the urinary organs from infancy. When three years of age he had a violent 
attack of pain in the region of the right kidney, for which he was leeched and 
blistered. He recovered for the time, but afterwards was seized with a pain 
lower down on the same side, attended with difficulty in passing water, and 
with bloody urine. From that time to the present he has almost constantly 
been troubled about these parts. The last summer, for one or two weeks, the 
symptoms seemed almost entirely to disappear, but for the past three months 
they have all been aggravated. He is obliged to pass his water every half 
hour, and in his sleep it escapes involuntarily. He cannot get into bed without 
assistance; cannot walk fast without pain; passes blood occasionally. His 
appetite is good, and, considering the suffering he has undergone, the flesh is 
firm, strong, and of good colour. 

On account of the size and hardness of the stone, and the age of the patient, 
I advised the operation of lithotomy, but the parents would not listen to a 
cutting operation, where any other method was available. I, therefore, deter- 



56 Warren, Ether in Lithotrity and Lithotomy. [July 

mined to etherize the patient, make an attempt with the crushing instruments, 
and if the stone was found to resist farther than was thought safe, to relinquish 
this operation and advise lithotomy, which his friends would probably consent 
to, when the former was found to be impracticable. 

On Nov. 16th the first operation was done, Drs. Minot, Adams, and M'G-owan 
assisting me. The patient was placed under the influence of chloric ether. 
An attempt was made to introduce the catheter, for the purpose of injecting 
the bladder, but as soon as it reached that organ a violent contraction took 
place, so that the instrument was embraced, and all manoeuvres of it prevented. 
The etherization was then pushed to total insensibility, which is usually mani- 
fested by the occurrence of stertorous breathing, and the perfect relaxation of 
all muscular actions. The bladder was now injected with the greatest ease, 
the crushing instrument passed in, and the stone seized. It measured one and 
a half inches. Attempts were made to crush it by means of the screw, but 
this was found impossible on account of its hardness. The hold was therefore 
relaxed, the stone seized in a new position, more on one side, and was then 
broken clown without any great violence. The fragments were then crushed 
a second and even a third time. 

During the operation the patient was very quiet. He voided the water 
before he became conscious, and was left in a tranquil sleep. A warm hip- 
bath was directed, and the free drinking of gum Arabic and water. 

20th. — He has suffered more or less from pain in the bladder since the 
operation. A number of fragments of the calculus have been passed, which, 
on being analyzed by Dr. Bacon, were found to consist of the oxalate of lime, 
combined with the triple phosphate, showing itself in glittering transparent 
crystals. The latter seemed to have been deposited on the surface, and were 
excessively sharp and irritating to the touch. 

For the last four days the boy has been up and about the house. To-day 
the operation was again repeated, the stone seized, and at first seemed to resist 
the action both of the screw and hammer, but with a little perseverance it was 
finally crushed by means of percussion. The urine that passed after the oper- 
ation was a little discoloured with blood, produced apparently by the action of 
the sharp edges of the calculus on the mucous coat of the bladder, as there 
were never at any period traces of its coats on the instrument. 

Professor May, of Washington, was present, and assisted me in this opera- 
tion. 

The following day he voided quite a number of pieces, and among others 
apparently the original calculus that had passed from the kidneys; it was of a 
lightish brown colour, about the size of a small bean. 

The operation was repeated six times at intervals of a week. The time 
devoted to the seizing of the stone was generally about five minutes. From 
the great hardness of its composition it could not be crushed into sand, as 
is the case with the phosphatic and uric acid calculi, but the fragments were 
large, and required each to be seized separately and crushed. 

Twice in the course of this period portions became engaged in the orifice of 
the urethra, and it was necessary to administer ether and extract them, as the 
parts were so excessively sensitive that nothing could be performed without 
the assistance of this agent. 

Finally, the last fragment of the stone, which for some days had been lodged 
at the neck of the bladder, and which I had once pushed back, became sud- 
denly fixed at the membranous part of the urethra, so as entirely to obstruct 
the course of the urine. 

In order to effect the dislodgment of this remnant, the patient was etherized 



1849,] Warren, Ether in Llthotrity and Lithotomy. 57 

with chloric ether. . Hunter's forceps were now introduced, and after some 
manoeuvres, and with considerable difficulty, the stone was at length caught and 
dragged to the fossa navicularis. From this spot it was found impossible to 
extract it without laceration of the urethra; the hold on it was therefore re- 
linquished. Forceps were now introduced, and attempts made to break it, 
which at first were ineffectual on account of its extreme hardness ; but by 
perseverance, and by breaking it away gradually, this was at length effected, 
and the whole removed. No bad effects followed this apparent violence in- 
flicted on the urethra. From that time the symptoms of stone were entirely 
relieved, and the patient has now perfectly regained his health. 

At present, he passes water no oftener than natural, which is remarkable, 
considering the constant irritation kept up in the bladder for a period of thir- 
teen years. 

The following case of stone, in which the operation of lithotomy was per- 
formed, possesses some interest, both from the manner of the formation of the 
calculus, and from the great assistance afforded by the ether in the examina- 
tion of the bladder, and the subsequent operation. This case has already been 
referred to by Dr. J. C. Warren, in his "Remarks on Etherization." 

Case YII. — On Nov. 7th, 1847, I saw, in consultation with Dr. Morrill, a 
little child of Mr. Colbeck, four years of age, affected with symptoms of some 
foreign substance in the bladder. The child was thin, delicate, and tall of his 
age. The history of his present disease was as follows. 

Two years and a half previous, as the child was making water in the street, 
another boy, in attempting to wrest a knife from him, pulled him over and 
dragged him through a heap of gravel. When taken up by his mother, a 
quantity of this substance was found adherent to the glans penis. For twent}^- 
four hours he had an almost complete stoppage of water. At the end of that 
period an examination being made, disclosed a small bit of gravel lodged just 
within the orifice of the urethra. It was removed by a knitting-needle, and 
immediate relief obtained. 

Some months after the preceding occurrence, the child began to complain 
of difficulty in passing his water, attended with frequent desire to evacuate 
the bladder. These, with intervals of ease, have continued till within a few 
months. Since then the symptoms have become much aggravated, so as to 
make it imperative to have active measures taken for his relief; the sufferings 
both by day and night being almost constant, and the calls for evacuating the 
bladder incessant. 

All attempts at the introduction of a sound being resisted by the patient, 
he was etherized, and I at once discovered a calculus. At a subsequent period 
he was again sounded, and the stone detected. 

On Nov. 16th, an operation having been determined on, the child was fully 
etherized, and a sound being placed in the bladder, the stone was felt by all 
the gentlemen present ; viz. Drs. Warren, Townsend, Morrill, and Parkman. 
Lithotomy was immediately performed by the bi-lateral method ; the incision 
of the prostate being made with a straight probe-pointed bistoury. The stone 
was removed by a large polypus forceps. 

No bad symptoms followed the operation. On the following day the water 
passed by the urethra; on the third by the wound; and continued to do so 
for a week, when it resumed its natural course. 



On page 95 of the " Appendix to Etherization, with surgical Remarks," 



58 Warren, Ether in Lithotrity and Lithotomy. [July 

already alluded to, will be found a description of the stone, with some comments 
upon its presumed method of introduction, by Dr. J. C. Warren, in these 
words : — 

" The stone was about half an inch long, the fourth of an inch thick, and 
in form of a flattened oval. It was sawn by Dr. J. B. S. Jackson. The ex- 
terior layer consisted of a whitish deposit, the sixteenth of an inch in thickness, 
and composed apparently of triple phosphate. The layers within this were 
of a brownish colour, like that of the phosphate of lime, and were about half 
a line in thickness. In the midst of these was a harder substance, about a 
line in diameter, which appeared to be silicious. Its outline could not be 
exactly distinguished from the surrounding layer of brown deposit. 

" The retrograde passage of the apparent nucleus into the bladder may ex- 
cite surprise, unless we take into consideration the inverted action of the ure- 
thra, by which bodies received into it are so often conveyed from without into 
this organ, where they serve as the nuclei of stones. The introduction of this 
nucleus may receive an additional explanation from the fact, that the gravel- 
stone, removed by the mother, prevented the passage of urine forced into the 
urethra by the strong contractions of the bladder, and this not escaping, was 
driven back by the contractions of the urethra, carrying along the inner stone, 
which formed the nucleus. 

It will be evident, on a review of the above cases, that lithotrity would have 
been impracticable in the first, second, and sixth instances, had it not been 
for the great assistance afforded by etherization. The quietness with which 
the preliminary examinations were allowed, may be strongly contrasted with 
the manner in which these are frequently done, amidst the struggles of the 
patient, and the violent contractions of the bladder; while the surgeon is left 
dissatisfied and uncertain, and finds himself obliged to make one or two repe- 
titions before a sufficiently accurate diagnosis can be made to warrant him in 
proceeding to a surgical operation. 

I was much struck by this fact shortly after etherization was introduced 
among us, when called in consultation to a female labouring under the symp- 
toms of stone in the bladder. It was agreed that she should be sounded, and, 
if a stone was discovered, that lithotrity under ether should be done on the 
following day. The sounding produced the most severe suffering, on account 
of the extreme irritability of the mucous coat of the bladder, added to the 
natural sensitiveness of the patient. A stone was struck, and, by the intro- 
duction of a finger into the vagina, the sound being in the bladder, it could 
be embraced between the instrument on one side, and the finger and vesico- 
vaginal septum on the other. It was apparently adherent ; but in consequence 
of the contractions of the bladder, and the struggles of the patient, the ope- 
ration was rendered extremely difficult. 

On the following day I visited her with the intention of performing litho- 
trity, but found, however, that during the night, owing to the violent expulsive 
efforts produced by sounding, and which had continued afterwards, the calculus 
had become detached and expelled : it was about the size of a bean. As some 
of the symptoms of stone persisted, it was determined to make another exa- 



1849.] Peebles on Nitrate of Silver in Jaundice. 59 

urination, to satisfy ourselves that the bladder was free from any further foreign 
substance. At this time ether was given, and every part of the bladder ex- 
plored with the catheter, without the slightest complaint from the patient. 
No obstruction was made to the free use of the instrument by the irritability 
of the bladder, which had on the day previous so much impeded the necessary 
manoeuvres. 

Although the experience of lithotrity under the use of ether is thus far 
limited to a few cases, yet we think these are sufficient to show that this opera- 
tion will probably assume greater importance, and come into more general use, 
now that a repetition of the requisite manipulation can be made without suf- 
fering. In many cases which hitherto must have been submitted to lithotomy, 
on account of the extreme irritability of the organs concerned, lithotrity will 
hereafter be adopted in preference. 

The case of cystic oxide calculus given above is interesting from the extreme 
rarity of this kind of stone. M. Civiale, whose great experience is well 
known, in his work on the stone and gravel, published in 1840, states that he 
has met with but four cases of it. In the Hunterian Museum, out of six 
hundred and forty-nine calculi, it appears by the catalogue there are but three 
of the cystic oxide. 

It has been stated that an hereditary disposition existed in many of these 
cases; two of those under the care of M. Civiale were brothers. In the pre- 
sent case this disease was not inherited, according to the account of the patient. 



Art. IY. — On Nitrate of Silver in Jaundice. By J. F. Peebles, M. D., of 

Petersburgh, Va. 

The value of nitrate of silver in jaundice was revealed to me incidentally. 
A man, who had been completely jaundiced for a period of two months, con- 
sulted me about some troublesome stomach symptoms. The patient had im- 
bibed the impression that mercurials would be deemed necessary for the re- 
moval of his jaundice, and having a deep-rooted prejudice against that whole 
class of remedies, he begged that I would take no notice of that disease, which 
really annoyed him but little, and prescribe exclusively for his gastric distress. 
I ordered him the crystallized nitrate of silver, conceiving that remedy indi- 
cated for these latter symptoms. 

He was not seen again for a week. The jaundice, then, had entirely disap- 
peared, and the patient had already discontinued the medicine, believing him- 
self cured. At my suggestion, however, he continued its use several days 
longer, and since that time, a period of nearly three years, he has had no re- 
turn of the icterus, and has in every respect enjoyed excellent health. Since 



60 Peebles on Nitrate of Silver in Jaundice. [July 

then I have on many occasions tested the value and verified the efficacy of this 
remedy in the treatment of chronic idiopathic jaundice. 

I am aware that various remedies have been from time to time promul- 
gated, and held in high repute for the treatment of this disease, or more 
properly, symptom of disease; and that many such should find favour, is not 
inconsistent with our knowledge of the nature of jaundice. 

Whilst thus admonished against an unnecessary enlargement of this list, I 
am yet emboldened to urge this simple method of treatment in uncomplicated 
jaundice, — in those cases, in short, in which the removal of the hue of the 
tissues is the most prominent indication ; for the following reasons: First, it 
is prompt and efficacious; secondly, it produces neither sickness nor disturb- 
ance of any kind; and lastly, its dose is small, and the form of its administra- 
tion agreeable and convenient. The latter reasons are really more weighty 
than would seem at first sight. Many jaundiced persons are but little com- 
plaining, and often are about as usual. To such, it is clear a remedy would 
strongly recommend itself, which was characterized by an insensible action, 
and an entire absence of all annoying influences. 

Jaundice we know is removed every day by various means, but it is surely 
a desideratum with the physician, one which is always appreciated by the pa- 
tient, to select those agents which will effect his object with the least possible 
inconvenience to the sufferer. 

It is not my purpose to go into the pathology of jaundice. But, as it has 
already been intimated, that the treatment is not of universal application, it is 
necessary that I should expose the principles which have guided me in its em- 
ployment. My remarks, therefore, shall be confined to the delineation of so 
much of its nature as will be necessary for this object. 

Icterus is often of simple origin. A man may become completely jaundiced 
before he is aware of any very marked deviation from his usual health. 

An emotion of the mind has been known to produce it. In such cases 
there always exists a predisposition ; and I have observed that this predispo- 
sition consists in a chronic gastric disorder, often too little manifested to excite 
the patient's attention. Dyspepsia and chronic gastric irritation, therefore, are 
the chief predisposing causes of this form of jaundice. Three-fourths of these 
cases coming under my notice have occurred in persons addicted to the exces- 
sive use of tobacco. The method by which this habit produces the predisposi- 
tion is of easy demonstration; it establishes chronic irritation of the gastric 
mucous membrane, which irritation, as well as the jaundice which follows, is 
speedily removed by the use of the nitrate. The co-existence of jaundice with 
disease of the primse vise is well enough known. It generally, to some extent, 
accompanies ileus. Nor is the recommendation of remedies for its removal, 
addressed solely to the stomach, possessed of any novelty. In simple chronic 
idiopathic jaundice the stomach is always the most complaining. It is often 
preceded by a disposition to spit up the food, of several months' duration. 
Then the urine is observed to gain, and the feces to lose, colour. The gastric 



1849.] Peebles on Nitrate of Silver in Jaundice. 61 

distress increases as the disease progresses; and when it is fully developed the 
blandest article of diet creates a most unpleasant feeling of distension and 
weight in the stomach. There is, in addition, pain in the epigastrium, extend- 
ing around, and sometimes covering, the entire hepatic region. It is in such 
cases as these that the nitrate of silver has proved itself of such benefit. 

The method by which the remedy is supposed to act in the cure of jaundice, 
can be readily divined after the above hints. This method is, in my opinion, 
clearly illustrated by its prompt action in the following case. A man, who, 
previously to the attack, had suffered several months from a tendency to diar- 
rhoea, whilst just beginning to convalesce from pneumonia rapidly became 
jaundiced. His acute pulmonary disease had been treated by local depletion, 
calomel, and opium, and he was slightly ptyalized. After having for some days 
a dry and loaded tongue, the crusts broke away leaving a clean, glazed, and 
very red surface. 

It was precisely at this juncture that jaundice manifested itself. Here there 
existed unequivocal testimony of gastro-enteric irritation. The condition of 
the mucous surface of the internal organs became itself a separate disease, 
and, as the pneumonia was decidedly on the wane, nitrate of silver was ordered 
for its removal. 

The patient took two doses, and in eighteen hours the hue of the tissues had 
disappeared, and there followed a rapid decrease of colour in the urine with 
return of healthy alvine discharges. On the third day not a trace of the jaun- 
dice existed. Nitrate of silver according to this, it appears, cures jaundice by 
modifying the condition of the mucous membrane of the stomach and primse 
vise. 

Stronger proof illustrating this point could not, in my opinion, be adduced 
than that afforded by the case just quoted. 

This view of its mode of operation, it will be perceived, brings down the 
pathology of jaundice within very narrow limits; and the question, Can simple 
gastro-enteric disorder of any kind give rise to jaundice? at once arises. Only 
an approximation to a perfect solution of such question is at present attainable. 
Facts sufficient exist, however, it appears, to warrant such an inference. Drs. 
Graves and Stokes long ago held that jaundice might arise from the presence 
of glairy mucus in the duodenum, obstructing the orifice of the common duct; 
and most writers mention that it may arise from turgescence of the coats of 
this intestine. Now, the presence of viscid mucus in the duodenum clearly 
indicates a modified and deranged state of its mucous surface, a fact which, if 
the views we have above expressed be correct, is of itself sufficient to give rise 
to jaundice without the supposition of an obstruction of the common duct. 
That such obstruction is not necessary to originate jaundice is well known. 
The disease does not always exist when it occurs, and it is often present when 
there is proof of no such obstruction existing. But whether this be necessary 
or not, we have the authority of these able physicians that the disease may 
originate in the duodenum. This is one of the most interesting points in the 
No. XXXY.— July ; 1849. 5 



62 Peebles on Nitrate of Silver in Jaundice. [July- 

whole inquiry. It separates the disease — we mean that form of it under con- 
sideration — from the idea of hepatic disorder, and has great practical bearing 
upon its treatment. 

I confess, my opinion, that original hepatic disorder is absent in simple 
idiopathic jaundice, if not formed, was certainly confirmed by witnessing the 
action of nitrate of silver in its removal. In none of the cases treated have 
I found it necessary to resort to mercurials or other cholagogues, to restore pro- 
per hepatic action; on the contrary, I have invariably found this to occur with- 
out such agents, indicated by healthily coloured alvine discharges, appearing 
always subsequently, although in a few days after the skin begins to clear, and 
by the recovery of the tone of the digestive organs. 

The part which the liver plays in its production is not of easy solution. We 
know that extensive disease of the organ may exist without jaundice. 

The idea of cystic obstruction causing re-absorption of bile is not now uni- 
versally entertained by the best pathologists. Pain in the hepatic region, it is 
true, accompanies the disorder. We know, also, that it is attended by nephritic 
uneasiness; yet no one will say that disease of the kidneys exists, apart from 
an irritation of those organs, palpably due to the excess of new matter in the 
urine. A similar cause, it may be fairly urged, gives rise to the hepatic un- 
easiness. 

The tendency of modern investigation points more to the assimilating 
functions for an explanation of jaundice. Bile pigment is in excess. Sherer's 
analysis of the bile found in the gall-bladder of a jaundiced girl, demon- 
strated that its preponderance over that in healthy bile was enormous. He 
contends also that only this pigment and not bile elements is found in the 
urine. Simon, although he asserts that these latter do exist in the urine of 
jaundiced patients, yet evidently shows that their presence is not universal. 
Lecanu found only bile pigment in the blood of jaundiced patients. Further 
speculation respecting the origin of jaundice, however interesting, is not ne- 
cessary for our present design. We set out to prove that there was nothing in 
the nature of idiopathic jaundice inconsistent with the idea of nitrate of silver, 
from its known effects on the system, having power to remove it, and we trust 
we have effected our object. Only a few words will be necessary to devote to 
its manner of administration. 

The treatment is begun by giving f to a grain of the crystallized nitrate 
of silver twice a day. It is important that it be given on an empty stomach. 
The remedy I have found will remove the disease without this precaution, but 
much sooner with it. Ten days I have found the utmost time required; often 
improvement is observed in the hue of the skin on the second day. 

But the patient experiences great relief immediately. The uneasiness of 
the stomach and the sense of fulness after eating disappears, and there is im- 
provement in the digestion. When the disease is accompanied by constipation, 
as it often is, for the sake of convenience a laxative is combined. A pill, given 
twice a-day, of 1 gr. argent, nitr. cryst., 3 grs. p. rhei, ext. taraxac. qs., an- 
swers a good purpose. Of course the patient must observe an unirritating diet. 



1849.] Hartshorne's Notes of Hospital Cases. 



Art. V. — Notes of Hospital Cases. By Henry Hartshorne, M. D., of 

Philadelphia. 

Nitrate of Silver in Chronic Gastritis. — By patients affected with indiges- 
tion accompanied by epigastric tenderness, very positive advantage was derived 
under Dr. Wood's treatment from the use of the argent, nitrat., — beginning 
with gr. I and increasing to gr. |, thrice daily, with half the quantity, or less, 
of opium. In some instances vomiting, before frequent, ceased on the admin- 
istration of this combination in pill. No other remedy seemed so particularly 
adapted to the chronic inflammation of the primae viae, which constitutes one 
form of dyspepsia. 

Chronic Dysentery treated by Sulphate of Zinc Encmata. — One case of three 
months' standing, was relieved entirely in a few days by the use, twice daily, 
of an injection of four ounces of water, containing eight grains of zinci sul- 
phas, with forty drops of laudanum. 

One much more recent, originating in the house, but resisting the ordinary 
astringent and opiate preparations, was cured by a single enema containing a 
scruple of the sulphate, with starch. This last application, however, was 
somewhat painful, from the strength of the solution. 

Neuralgia. — In the cases noted, this obstinate disorder received but a pal- 
liative impression from ext. belladonnas, except where combined with ferri 
carb., to which tonic the curative effect might be ascribed. 

As an external application, the saturated tincture of aconite root was found 
the most efficient agent, perhaps not even excepting the veratria ointment. A 
considerable number of patients were at once relieved of tic douloureux, lum- 
bago, &c, by a few applications of this tincture. Its internal use was not so 
obviously beneficial, perhaps from the smallness of the dose. 

Neuralgia relieved by Venesection. — A female patient, aged between fifty 
and sixty, confined to her bed with a fractured thigh, had been long subject to 
severe pain connected apparently with the supra and infra-orbital nerves of 
one orbit. After confinement for several weeks on her back, she was affected 
with symptoms threatening apoplexy* and was bled moderately from the arm. 
The neuralgic pain from this time ceased and did not return while she was in 
the house. 

Hemicrania treated by Quinine and Valerian. — Thomas Barker, aged thirty- 
five, for two months before entering the hospital had suffered from severe pain 
in one side of his head, with slight roaring in the ear, and also pain in the 
same side of the body, about the lower ribs. No evidence of pectoral disease 
existed, and none of cerebral — more than the slight noise in the left ear, and 
perhaps a very little hardness of hearing. 

Quin. sulph., gr. xvj, with ol. valerian, gtt. xxx, were given in divided doses 
through the day, after purgation by a colchicum mixture. He was a little 
better the first day, but worse the next two. The quinine was then increased 



64 Hartshorne's Notes of Hospital Cases. [July 

to gr. xxiv daily, and lie took at bedtime vin. colch. rad., gtt. xx, with liq. 
morph. sulphat., f3ij. Under this treatment he improved at once — the pain 
both of his head and side left him entirely — the medicines were gradually 
diminished in dose, and in a few days he went out well. 

Intermittent Neuralgia with two weeks interval. — Garrett Joyce, aged thir- 
teen, had for several months regularly recurring attacks of intense pain over 
the left brow and in the eye — at intervals, first of a month or two, gradually 
lessening down to two weeks, when he was admitted to the hospital. The 
pain lasted for two or three days, and then for two weeks he was perfectly well. 
The interesting fact with regard to it was, that it entirely resisted the action 
of quinine as an antiperiodic, freely and variously given, for several different 
intervals. The only effect produced was the postponement of the paroxysm 
for a day or two. Ferri sub. carb. and ext. belladonnse were next tried, without 
the slightest influence. A blister was then made to draw upon the nucha just 
at the expected time, and dressed with morph. acetat. ; but the pain came on 
as usual. Cupping produced slight palliation. Purgation during the inter- 
mission effected no change. Concentrated tincture of aconite root was ap- 
plied during the attack, and administered internally for several weeks, with no 
perceptible result whatever. 

The boy's health continued apparently perfect in the intervals, but the parox- 
ysm was regular to a day. 

Quinine in Intermittent. — No good reason appeared in cases observed for 
preferring five or six grain doses several hours apart, to one or two grains every 
hour; in fact, the resistance of the stomach often compelled the latter to be 
chosen, in the form of pill, with small portions of opium when the bowels 
were also irritable. In two or three cases of pernicious intermittent, thirty-six 
grains were required to check a paroxysm. Such cases rarely occur in the 
hospital. 

It was proved repeatedly that the presence of headache, jaundice, or local 
determinations during the intermissions of miasmatic fever, did not contrain- 
dicate quinine. Such symptoms, in three very decided cases, were promptly 
removed under its influence, with the ague. 

Remittent fever presented abundantly in the fall, in some cases of consider- 
able violence, from southern ports, as well as from the neighbourhood of the 
city. The treatment was almost invariably successful with Dr. Grerhard, by 
early purgation, occasionally venesection, and quinine on the first commencement 
of remission. In threatening cases it was given without waiting for such a 
change, and produced it. 

The impression was formed, that of the two elements of fall fever — the fe- 
brile condition and the miasm-cause — it is the latter only that is addressed by 
the remedy in question. It arrests fever by acting as an antidote to the poison 
which produces it. 

Can such facts then point to its use with a similar intention in the exacer- 
bation of other fevers, entirely different in cause, as the typhus and typhoid ? 
Certainly not. 



1849.] Hartshorne's Notes of Hospital Oases. 65 

The writer saw no facts, in any case of its administration, to justify any 
other appellation for its effects than those of tonic and nervous stimulant. The 
large quantities in which some southern practitioners assert it to have a sedative 
action on the pulse, were not given; and probably all such action is to be as- 
cribed to one of two causes — either cerebral oppression, analogous to narcotism, 
or the antidotal influence above spoken of, under which fever is arrested as a 
symptom of miasm-poisoning, by its specific. 

Typhus Fever. — Of the "ship-fever'' prevailing so extensively during last 
winter, a considerable number of cases entered the hospital, although never 
more than five or six were allowed at one time in the wards. For many years 
instances considered to be of true typhus fever had occasionally occurred; but 
never, unless in one individual, had it extended to others in the house. 

Nor did the character of active contagion display itself during this epidemic; 
although, after a succession of cases had been for some months in the wards, 
a manifest prevalence or infection was observed — affecting several patients 
entered for other complaints, the watchman of the house, who fell a victim to 
its violence, and myself, then resident physician. 

Five fatal cases were noted : one from the complication of acute laryngitis 
in the advanced stage. The others sank away with no manifest organic lesion. 
In one, the only post-mortem sign was a very slight and confined softening in 
the centre of the brain; in others nothing was detected. 

All had sudaminse, deafness, and stupor; several, subsultus tendinum and 
low, muttering delirium; others, a more active and restless wandering. Upon 
all was found a measles-like eruption, differing from that of typhoid fever in 
not disappearing under pressure, and in existing all over the body and limbs. 
The worst had decided petechiae; several, diarrhoea; several, bronchitic irrita- 
tion; and some, epistaxis. There was no characteristic odour about any of 
them. A tabular or numerical catalogue of cases and symptoms, in a number 
below one hundred, would avail no more than general results. 

They differed from the ordinary cases of continued fever, called typhoid, 
from the city and elsewhere, not only in origin, but in physiognomy, rapidity 
of sinking when fatal, the character of the eruption, less frequency of intes- 
tinal disorder, and more rapid convalescence. An opportunity occurred to 
Dr. Wood of making a distinct diagnosis during the life of two patients, and 
confirming it by the post-mortem comparison. In one was found very striking 
enlargement, as well as ulceration of the glands of Peyer; in the other an 
entirely different appearance of the intestine. Excessive development of those 
glands was sometimes observed, but no ulceration of them, in cases of ship- 
fever. 

At least half of the cases were treated without stimulation, beyond the 
use of quinine in grain doses after the febrile crisis had arrived. This term 
is used because a period was distinctly marked in several cases besides my own, 
after which excitement gave way to debility < } as the character of the condition. 



66 Hartshorne's Notes of Hospital Cases. [July 

This was noticed both in favourable and unfavourable cases ; as the time when 
excitant medicines were best borne. 

In many, however, at this late stage, and in some from the beginning* 
stimulus was called for and was liberally used. Almost all the fatal instances 
were of those who were admitted in a prostrate condition after some weeks' 
illness, and did not react under brandy-punch, oil of turpentine, and carbonate 
of ammonia. Some patients who recovered had been bled before admission, 
and one suffered, just before death, from phlebitis in the vein which had been 
opened. None were bled in the house. Venesection and free leeching were; 
however, used in my own case at the onset, with great relief and advantage. 

Undoubtedly, constitutional condition is of great consequence in determining 
the value of antiphlogistic treatment in this disease. In those depressed by 
suffering, sea-travelling, and starvation, it may be almost an axiom that " stimu- 
lation is essential in typhus.'' But from the personal experience of an attack, 
otherwise treated, although attended with very considerable prostration in its 
course, it appears evident that typhus may occur in individuals and in modes 
in which the lancet may preserve when alcohol would destroy. 

But in depressed cases with little vigour of reaction, the action of wine whey, 
in even a positively febrile state, with full, accelerated pulse, and hot, dry skin, 
of a few days' standing, was in some instances noted as promptly beneficial. 
It was frequently the only remedy prescribed by Dr. Gerhard, and appeared 
in such to be an excellent stimulating diaphoretic. This was, perhaps, some- 
times the case when a stronger excitant would have done harm. 

Typhoid Fever. — It may be again merely remarked that sufficient evidence 
appeared to be given of the propriety of a diagnosis between ship-fever, and 
other forms of typhus, and the ordinary continued fever of this country, as it 
appears in the hospital at all times — designated typhoid fever. A number of 
very striking dissections were made in the institution, showing palpably the 
peculiar lesion of dothinenteritis. This does not, of course, prove the enteric 
lesion to be the cause or main feature of the d : sease, nor interfere with the 
fact that, in a number of true ship-fever cases, diarrhoea, tympanitis, and ab- 
dominal tenderness occurred. 

In one patient admitted after a month's illness, supposed to be with typhoid 
fever, death, caused by intractable peritonitis, allowed us to discover perforation 
of the intestine. The same termination was inferred to have resulted in a 
young man who died suddenly a few days after being discharged as cured of 
a distinctly marked attack of that fever. The complication of pneumonia 
destroyed several cases in the winter of '46-7. 

Coup de Soldi. — On the 11th, 12th, and 13th, of 7mo. 1846, four cases 
of sun-stroke were brought into the hospital. Several others occurred in the 
city during the same intensely hot days, all reported as fatal. 

The first admitted was, when brought in, nearly pulseless, and unconscious; 
head very hot. Ice was at once applied to the head, two or three dry and one 
or two cut cups were placed on the back of the neck, and carbonate of am- 



1849.] Hartshorne's Notes of Hospital Cases. 67 

monia and brandy punch, were administered by the mouth. Sinapisms were 
also applied to the extremities and epigastrium. Reaction gradually came on, 
the skin becoming at last intensely hot, and active delirium supervening for a 
few hours. The stimulus was withdrawn, and the fever was only of about 
twenty-four hours' duration. This patient was a temperate man, aged about 
thirty years. 

The second was a man notoriously intemperate in his habits. His pulse 
when he was brought in was full; breathing stertorous; stupor complete; pupils 
contracted; skin very hot. He vomited repeatedly. Ice was put around the 
head, and mustard to the abdomen and legs, and cut cups, which brought very 
little blood, to the nucha and temples. He could not be made to swallow 
anything; an enema of spirits of turpentine was administered. He died about 
two hours after admission. 

The third case was entirely moribund when brought there, and expired in 
less than ten minutes. He was said to have been a temperate man, waiter at 
a hotel; a little unwell the day before, but walking about at noon of the day 
of his death. The precise history of these cases, as to the amount of fatigue 
and exposure, we could not learn. 

The last was a mild attack. A young man while walking in the sun carry- 
ing a bundle, was attacked with intense headache, vomiting, and purging. 
When he entered the house, several hours having elapsed, his headache was 
still great, stomach sick, pulse accelerated and somewhat feeble, head warm. 
He was put into a warm sitting-bath, with a cold douche on his head, and 
twenty drops of spirit, amnion, aromat. were given every half hour for an hour 
or two. The case seemed then to resolve itself into one of simple fever, and 
was treated by ice to the head, and the liq. ammon. acetat. He entirely re- 
covered in a few days. 

Meningitis. — An acute case of great violence, under Dr. Wood, exemplified 
the use, after free venesection, &c, of a blister to the whole scalp; and also 
the safety of free stimulation after such an inflammation, when required by 
the condition of the forces. He recovered fully. 

A man suffering with chronic meningitis, following an acute attack, evinced 
an immediate improvement on the breaking out and subsidence of a mild ery- 
sipelatous eruption on the face. The commencement of his cure was dated 
from that event, and it was soon completed. 

A negro with acute bronchitis, somewhat obstinate, recovered also imme- 
diately on the breaking out of erysipelas of the face and neck, seeming to be 
critical. 

Use of a Seton. — This remedy is so disagreeable as to make all facts in its 
favour interesting. An Irishman, named Macbeth, who had slight paralysis 
and frequent convulsions, or rather fainting fits, for several months, was cured 
of these symptoms entirely in about four weeks by little treatment besides a 
seton in the back of the neck. 

This man had a singular fancy. He said, that "he could think, remember, 



68 Hartshorne's Notes of Hospital Cases. [July 

and calculate, much better with the left side of his head than with the right — 
of which he had almost lost the use/ 7 Are there not some facts which seem 
to show that the brain is a double organ, like those of the senses which origin- 
ate from it ? 

The seton was also found a valuable agent in treatment of obstinate hysteria. 

Local Paralysis cured. — A bricklayer was admitted who had lost the power 
of extending or forcibly flexing the fingers of the left hand. The arm was 
unaffected. He had first noticed the paralysis on waking in the morning, a 
week or two before. The only cerebral symptom was at that time a sense of 
heaviness and unusual drowsiness. The treatment by Dr. Pepper was purga- 
tion, cupping to the nucha, and a blister to the forearm, dressed twice daily 
with pulv. strychnine, gr. ss. In a week he had almost entirely regained the 
free use of the hand. 

A few months afterwards another case, exactly similar, occurred in the 
wards. 

Acetate of Lead. — The capacity of this preparation to produce symptoms of 
lead poisoning was demonstrated in two or three cases of aneurism of the aorta 
in which it was therapeutically used. 

Paralysis of the Bladder treated by cold Lnjections. Hinchman, an 

old man, was, on entering the hospital, entirely unable to dispense with the 
use of the catheter, twice a day. This state continued for several months. 
But after commencing the use of cold water injections every day through a 
catheter, aided by strychnia internally, in one month he acquired the power of 
relieving himself always without the instrument. He expressed great imme- 
diate relief from the injection, of the sense of irritation existing in the bladder. 

Gatheterism. — Perhaps it is a familiar fact to all surgeons, that in patients 
with enlarged prostate the best position for the introduction of the catheter 
is the standing posture. Gravitation thus assists the removal of the gland 
from the urethra. It is noted merely as having been proved in several instances 
by the house surgeons on duty in the hospital. 

Phthisis PulmonaUs without Symptoms. — I omitted to mention in a previous 
connection the case of a man admitted in the winter of 1847, whose only com- 
plaint was of general debility. He was about forty-five years of age. He had 
no cough, sputum, nor pain in the chest. A physician had told him that his 
lungs were perfectly sound; but auscultation soon revealed the existence of 
pneumothorax of the left side. He died in a few days. The autopsy dis- 
played the left lung to be a collapsed mass of tubercle in the bottom of the 
chest, leaving a depth of four inches between it and the ribs, half filled with 
serum. The right lung was also tuberculous, but capable of respiratory action. 



1849.] Thweatt, Oxide of Silver in certain forms of Menorrhagia. 69 



Art. VI. — On the use of the Oxide of Silver in certain forms of Menorrhagia^ 
with Oases and Remarks. By J. J. Thweatt, M. D., Petersburg, Va. 

The preparations of silver have recently attracted considerable attention, 
especially in diseases of the mucous membranes, attended with undue secre- 
tion. I was led to try the powers of the oxide of silver in menorrhagia and 
irregular menstruation, from the high eulogy passed upon it by Dr. Lane; and 
the success which followed its use was so encouraging as to induce me to 
direct my attention particularly to its mode of action, and the forms of menor- 
rhagia to which it is applicable. 

My experience with this medicine has now been sufficient to induce me to 
repose great confidence in it when properly and judiciously applied. I do 
not pretend to claim for it the appellation of a specific, but I am persuaded 
that, " ceeteris paribus," all that is claimed for mercury in syphilis, or quinine 
in intermittent fever, can be claimed for the oxide of silver in menorrhagia, 
in its different forms. It is eminently superior to the acetate of lead, and 
other mineral and vegetable astringents usually employed in this disease. 

The oxide of silver is best adapted to those forms of menorrhagia which 
depend on an undue excitation of the uterine organs, unaccompanied with high 
inflammatory action. Cases often present themselves where profuse hemor- 
rhage makes its appearance at the usual menstrual period, or immediately 
after it has passed; in these cases there is an extraordinary excitation of 
the nervous system. The oxide of silver here often acts like a charm : calms 
the perturbation of the nervous system, and arrests the hemorrhage by its 
astringent qualities. It should be given in large doses, and repeated at short 
intervals until some effect is apparent. "Women after parturition are frequently 
troubled with a sanguineous discharge, distinct from the lochia, which is dif- 
ficult to remove by the usual remedies. The oxide of silver is an infallible 
remedy for this pathological condition. 

There is one form of menorrhagia often met with, which often baffles the 
skill and experience of the ablest practitioners to remove; and I know of no 
form of disease which tries more the patience of both patient and physician. 
A remedy, therefore, in which any reliance can be put, is certainly a 
desideratum. I refer to the too frequent occurrence of the menses. The 
quantity of the discharge is sometimes larger and sometimes smaller than it 
naturally should be; the intervals are short, and, in many instances, the pa- 
tients are never entirely free from some discharge; exhaustion and debility are 
the usual accompaniments of this morbid condition; impoverishment of the 
blood followed by a cachectic condition of the general system; the nervous 
system is deeply involved; palpitations of the heart become a great annoyance. 
There is likewise a general depression of the moral faculties; the digestive 
organs are ultimately implicated, and there is dyspepsia in its multifarious 
forms, — gastralgia, pyrosis, &c. &c. Spinal irritation is of frequent occurrence; 



70 Thweatt, Oxide of Silver in certain forms of Menorrhagia. [July 

the patient complains during the short intervals (when there are any) of dull 
pains in the pelvic region, with the sensation of weight or a hearing down 
motion in the uterus. 

The oxide of silver is the only remedy in which any confidence can he placed 
to remove these symptoms. I have, under these circumstances, employed in 
vain the various preparations of iron and lead, together with the mineral acids : 
they afforded only temporary relief; hut in every case in which I prescribed 
the oxide of silver, its action has been satisfactory. 

I am aware that it is ' the opinion of those medical gentlemen who have 
experimented with this medicine, that it is inferior to the preparations of iron 
in those cases where the hemorrhagic tendency depends upon a general anemic 
condition of the system. This is the opinion of Dr. Lane ; it is with all due 
deference to such high authority, that I express a contrary opinion. In this 
form of menorrhagia the true indication to be met, is the arrest of the abnor- 
mal secretion; this drainage of the general system. If we can accomplish 
this (under all circumstances) desirable object, we will have paved the way for 
the use of the ferruginous preparations, and the carrying out beneficially the 
proper hygienic regulations for the restoration of the health of our patient. 

My experience with the oxide of silver induces me to believe that its main 
action is upon the capillary circulation, and particularly upon the uterine ca- 
pillary system; that its powers are specifically directed to the uterine system. 
Its operation upon the nervous system is that of a mild and unirritating tonic. 
It is almost superfluous to state that this medicine is entirely nugatory, if 
not prejudicial, in those cases of menorrhagia which depend upon organic 
lesions. It never should be prescribed in cases of high inflammatory action; 
until after the subjugation of the inflammatory symptoms by antiphlogistic 
means, when it may be administered with great benefit. 

I am in the habit of prescribing this medicine in larger doses than usual. 
The only pathological effects I have witnessed from its use, in two grain doses, 
two or three times a day, were uneasiness in the lower bowels, sometimes 
attended with slight tormina and tenesmus. These symptoms were easily 
removed by an anodyne enema. They often, however, require no attention 
on the part of the physician. The usual dose, when intended to be con- 
tinued for any length of time, is a half grain to one grain, twice or three 
times a day, according to circumstances : it should always be combined with 
a small quantity of opium or morphia. The oxide of silver blackens the 
stools. 

Subjoined are a few of the most important cases in which I have employed 
this remedy. 

Case I. — Oct. 1847. Mrs. T., mother of three children; has enjoyed gene- 
rally good health, with the exception of slight dyspeptic symptoms. For six 
months has been subject to an immoderate flow of the menses, which has weak- 
ened her very much; debility so great that she cannot take exercise without 
palpitations of the heart, with a sense of suffocation ; anorexia ; costive bowels ; 



1849.] Thweatt, Oxide of Silver in certain forms of Menorrhagia. 71 

condition of the system slightly anemic; pains in the pelvic region; menstrua- 
tion irregular, frequent, and abundant, intervals eight to twelve days ; does not 
believe that she is ever entirely free from sanguineous discharge ; no pain during 
menstruation. Ordered her the following pills: R. — Argenti oxidi gr. xij ; 
pulv. opii gr. i. Div. in pil. xij. One pill to be taken morning and night, 
bowels to be moved by enema. Saw her the third day ; had taken six grains 
of the oxide of silver; the discharge was diminished. Says she feels better 
than she has for six months ; appetite improved, bowels open. Ordered to 
continue the pills, mild nourishment, gentle exercise. Saw her again the sixth 
day ; had taken all of the pills, twelve grains of the oxide ; the discharge had 
entirely ceased ; says she is as well as ever she was : the dyspeptic symptoms 
had entirely disappeared ; general condition much improved ; discontinued the 
pills; ordered a generous diet. She menstruated healthily at the regular 
period ; has had no return of the hemorrhage; enjoys now excellent health. 

Case II. — Mrs.' ,set. 38, of a good constitution ; mother of five children, 
last child five years old ; health generally good ; for eight or twelve months 
has menstruated irregularly, menstruation attended with severe pains in the 
back, with a sense of weight in the pelvis ; the pains in the back continue with 
more or less severity, during the interval of menses; suffers very much from 
it ; the catamenia occurs every ten or fifteen days, quantity not too abundant ; 
lasts two or three days ; a very slight discharge from the vagina during the 
short interval ; all the other functions healthy ; prescribed cups to the spine, 
rest; and one of the following pills night and morning : R. — Argenti oxidi gr. 
v ; morph. acetat. gr. ss. Div. in pil. x. She took the pills during the interval 
of menstruation. I saw her after she had taken the ten pills, and found her 
condition much improved ; does not complain so much of pain in the back. 
The sensation of weight in the pelvis had almost entirely disappeared. Di- 
rected to continue the pills; bowels, if necessary, to be kept open by enema. 
Did not see her again for fifteen days, had menstruated after an interval of 
twenty days ; no discharge from the vagina, no pain in the back ; general 
health excellent ; discontinued the medicine and ceased my attendance. 

Case III. — Sept. 1847. Molly, coloured woman, of a sound, robust consti- 
tution, set. 42, had had several children ; was suddenly attacked, without any 
ostensible cause, with profuse hemorrhage. When I saw her, the blood was 
streaming from the vagina; pulse weak, very much alarmed; her menstruation 
had been regular up to this time. I ordered her immediately to take one of 
the following pills, every half hour, until I should see her. R . — Argenti oxidi 
gr. vi ; pulv. opii. gr. ss. Div. in pil. iii. 

I saw her after the lapse of an hour; had taken two of the pills; hemor- 
rhage had abated; was calm and tranquil; ordered the third pill to be taken. 
I saw her again at night, the hemorrhage had entirely stopped. On the fol- 
lowing morning, I found her entirely free from any disease. Ordered a 
nourishing diet, and left her. 

Remarks. — The above case was one of pure idiopathic menorrhagia, a form 
rarely met with. The case is a very interesting one, insomuch as it demon- 
strated the extraordinary efficacy of the oxide of silver. It will be perceived, 
that the oxide was administered in two grain doses, and frequently repeated, 
No bad effects followed these large doses. The therapeutic action of this 
medicine was rapid and certain. • 



72 Delaney, Congenital Phimosis. [July 

Case IV. — Feb. 27th, 1849. Mrs. , of a nervous temperament, been in 

delicate health for some time ; was suddenly seized without apparent cause, with 
pains in the loins and lower portion of the abdomen, quickly followed by con- 
siderable hemorrhage; became much alarmed; pulse small and quick. Skin 
bathed in cold perspiration ; pains in the back and hypogastric region, inter- 
mittent. Says she menstruated on the first of January, menstruated again 
ten days previous to the present attack, lasted only two days. Prescribed the 
following. R. — Argenti oxidi gr. vi ; morph. acetat. gr. % ; pulv. glycyrrh. q. s. 
Divide in pil. iij, one pill to be taken immediately and repeated in half an 
hour. (My friend Dr. S. A. Hinton here took charge of this case. I am in- 
debted to his kindness for the following report.) 

I saw the case after she had taken two pills of the oxide of silver ; the 
hemorrhage had greatly diminished; was quiet and tranquil. Ordered the 
third pill to be given. Saw her again at night; hemorrhage had almost 
entirely stopped; pain in the back and abdomen relieved. Discontinued the 
medicine. 

28th. Bowels rather loose ; complains of pain in the lower bowels, with slight 
tormina and tenesmus. Prescribed an opium pill, to be taken at bed-time. 

March 1st. Slept well during the night; no pain in the bowels or back, 
scanty discharge from the vagina. Prescription, a small dose of Henry's mag- 
nesia. 

2d. The discharge scarcely perceptible. Ordered rest, and a bland nourish- 
ment. 

3d. Doing well. 



Art. VII. — Congenital Phimosis. By M. Gr. Delanet, M. D., Surgeon U. S. 

Navy. 

Congenital phimosis is a more common malformation than physicians in 
general practice are aware of. 

In hospitals devoted to the treatment of venereal disease alone, many cases 
are met with. The best opportunity, however, for the observance of this de- 
fect is to be found in military practice; and particularly in that portion of it 
which includes the examination of recruits at a rendezvous. Within the 
space of two months I had examined and passed at the naval rendezvous in 
this city one hundred and seventeen men. Of these, twelve were affected 
with congenital phimosis; and all but two were impotent. All had attempted 
sexual union, but two only succeeded, according to their own statement, 
which, judging from appearances, I considered doubtful. 

The feeling of amativeness was so weak in these men, that they had essayed 
a connection with women rather from a sense of curiosity than passion. I 
have scarcely ever seen twelve men with more ample muscular developments 
in' all parts save the organs of generation. The respective ages were : 1 of 28 
years; 1 of 26; 1 of 24; 1 of 23; 4 of 22; 3 of 21, and 1 of 18 years. 

The penis was invariably small, or the size of that of a boy of twelve years; 



1849.] Delaney, Congenital Phimosis. 73 

coronal gland very small, and prepucial opening but little larger in diameter 
than the meatus. The testes, from having been but rarely excited, corre- 
sponded in size with the penis. The want of sexual desire, or the existence 
of impotency in these cases, is manifestly owing to the phimosis. The coronal 
gland, being bound down by the prepuce, could neither receive the necessary 
nervous stimulus, nor expand to the capacity requisite for virile enjoyment; 
consequently, in the majority of cases, congenital phimosis begets, what it only 
can beget, impotency. This misfortune can only be remedied by a surgical 
operation. The congenital impotent is a different being, in appearance, from 
the one who is a poor victim of masturbation. In the former case you may 
have the finest form with the most perfect health — a health never broken in 
upon by erotic ideas or wasting excesses — the latter I need not describe to any 
practitioner; — its suicidal wretchedness is known to all. 

Masturbation and congenital phimosis never exist together: they are, in a 
measure, physical incompatibles. 

A moral question may obtrude itself, whether the surgeon is justifiable in 
remedying a malformation which is a safeguard to virtue, and a cloak of pro- 
tection to its owner; but which, at the same time, renders him incapable of 
fulfilling the duties of the citizen, by marrying and raising up children. 

The necessity of an operation is not so imperative in this case, as in its 
parallel, a closed vagina, where the functional disturbance incident to maturity 
demands a division of the hymen. 

The Jewish rite of circumcision is founded in reason, and beneficial in re- 
sult. It may be said that every part given to us by nature has its use; it is 
so in a state of nature : but in one of civilization, the use of the prepuce can- 
not be designated with more accuracy than that of the thyroid gland. In the 
islands of the Pacific only has the prepuce a conventional usefulness. There, 
the otherwise naked native considers himself in full dress when the prepuce 
is drawn tightly over the gland, and its end tied up with a fanciful bit of 
sennet, or coloured grass. The native would no sooner be seen in the pre- 
sence of a woman with an uncovered gland, than would the civilized man 
without a shirt. There, then, and there only, does the prepuce subserve a 
material and fashionable purpose : which, however, gradually falls into disuse, 
in the progress of civilization. 

I have had occasion, in many instances, to circumcise natives of the islands 
— those acting on board whale ships as sailors. The prepuce, in those cases, 
served as a cloak to venereal matter, as well as to modesty; and had to be 
sacrificed. The most disgusting case of venereal is that wherein the mucous 
coat of the prepuce is plentifully studded with chancres. In fact, the great 
mortality following venereal in the Pacific Islands is owing — notwithstanding 
the constant habit of bathing — to this tying up of the matter of discharging 
chancres, in the bag of the prepuce. 

I would, therefore, recommend the adoption of the Jewish practice of cir- 
cumcision upon all children — not as a religious ceremony, nor before the end 



74 Delaney, Congenital Phimosis. [July 

of the first year — but as a preventive, in a certain degree, of venereal disease : 
and, in the absence of personal abuse, as a removal of the cause of impotency. 
In three instances I have slit up the prepuce in adults, for the relief of im- 
potency; and although the operation (as then practiced) left a flap neither 
ornamental nor useful, yet it subserved the main point ; and in two of the cases 
the men became reputable husbands. The best mode of operation is that 
recommended and practiced by Ricord : which is a great improvement, not 
only upon the Jewish, but every other method. His method is as follows : 
" The penis is allowed to remain in its natural position, and no traction is used : 
a circular mark is made with ink upon the prepuce, about two lines anterior 
to the base of the glans, and parallel to the corona : a long and strong needle, 
its point covered with a wax head, is then introduced between the glans and 
prepuce, and made to pierce the whole thickness of the latter, on the mesial 
line, and a little in front of the circular mark. The mucous membrane and 
skin of the prepuce are thus fixed, and the needle is allowed to remain. Be- 
hind it, and in a longitudinal direction, a fenestrated forceps, with notched 
edges, is then firmly applied. The fenestra of the instrument correspond to 
the circular mark and the glans ; at this stage of the operation the latter is to 
be pushed backwards. The next step is to pass sutures, five or six in number, 
through the fenestra; and when all the threads are applied, the prepuce is 
shaved off with a bistoury made to glide between the needle and forceps. The 
latter is then withdrawn carefully, so as not to disturb the ligatures. The 
assistant should be desired to press the forceps very tightly when the prepuce 
is being shaved off; if this be neglected, the prepuce will yield, and the sutures 
will be cut. When the forceps is removed, the arteries which are noticed to 
bleed, should be tied or subjected to torsion; the threads which pass above and 
below the glans are then divided in their centre, and the respective ends of 
each half resulting from this section are tied, to bring the mucous membrane 
in contact with the skin. Of course there will be twice as many sutures as 
there were threads passed." Treatment — the usual cold water dressing. It 
might not be correct to say that ten out of every hundred men, as in the 
present instance, are affected with congenital phimosis; but many are the 
unfortunate subjects of this malformation who live a single and unenviable 
life, without being able to fulfil the duties of men : and who, moreover, are 
deprived of that sympathy which other misfortunes elicit from our fellows by 
the secrecy which attaches to such cases. The operation upon the adult, though 
obviating impotency, yet does not visibly increase the bulk of the organ; 
which, compressed from infancy — unlike other parts of the body — had neither 
" grown with the growth, nor strengthened with the strength." 

The sum of human happiness and human numbers would be increased by 
the universal adoption of circumcision. 

Boston, May 1st, 1849. 



1849.] Clarke, Traumatic Tetanus treated with Chloroform. 



Art. VIII. — Traumatic Tetanus treated with Chloroform. Recovery. — Read 
before the " Boston Society for Observations in Medicine and the Collateral 
Sciences." By Edward H. Clarke, M. D. 

D. L , male, married, set. 27, is a native of St. Thomas, but for several 

years past has been a resident of Boston. Was formerly a sailor, but three 
or four years since commenced the occupation of a stevedore. Hair and eyes 
brown j smokes tobacco a great deal : otherwise temperate. Of nervous tem- 
perament, medium stature, muscular, but spare and thin. According to the 
statement of his wife, was attacked with trismus two years since, in the island 
of St. Thomas, which followed a scratch upon his face, and from which he 
readily recovered. 

On the morning of February 28, 1849, he wounded the back of his thumb 
slightly with a saw. As the wound bled but little he paid no attention to it, 
but continued his work as usual throughout the day, and slept well at night. 
During March 1st he complained of feeling restless and uneasy, and discon- 
tinued work earlier than usual on that account, but was not troubled by the 
wound. He did not sleep well that night; and on the morning of March 2d, 
said his thumb was " sore," and poulticed it. Being unable to work on ac- 
count of his uneasy sensations, he called for relief at the office of a neighbour- 
ing physician, who prescribed a cathartic pill, containing blue mass, to be 
followed by a senna draught. His sleep was again disturbed, but he felt better 
on the next morning. He was "not right," however, as he expressed it, and 
ascribed his uneasy sensations to the medicine, which produced two or three 
copious dejections. The poultice upon his thumb was continued. He was 
restless during the next night, but felt pretty well on the fourth. Had two 
dejections during that day, and vomited twice. Wound was not painful, but 
poultice was continued. Slept well during the night of the 4th, and rose the 
next morning, thinking that he had fully recovered. Soon after getting up, 
however, was obliged to lie down again, on account of a " feeling of faintness," 
accompanied with dyspnoea. 

I was called at ten A. M. of March 5th, and found the patient in bed, and 
presenting the following symptoms: Decubitus dorsal; countenance anxious; 
brow knit; mental faculties undisturbed; pulse 120, small and hard; respira- 
tion varying from forty to sixty in the minute, short and catching; could not 
auscultate the lungs on account of restless condition of patient; refuses to 
speak, or cannot speak; slight rigidity about muscles of neck; deglutition dif- 
ficult, and attended with a spasmodic cough, which has a stridulous sound ; 
opens mouth with difficulty; tongue moist, with a yellowish-white coat, thin 
at the edges, but thick at the centre. Bowels were freely moved yesterday; 
severe pain, not increased by pressure, just below true ribs on left side. His 
wife says that he has complained, for last hour or two, of great soreness and 
burning in his throat. Skin dry; extremities cool, but not cold. 

Being unable to get at the true history of the case at that time, it was 
thought that the disease might possibly be of a mimotic character. Accord- 
ingly, sinapisms were applied to the neck and feet, and an antimonial solution 
given : not strong enough, however, to produce emesis. Respiration soon fell 
to 25, and pulse to 90, in the minute. Deglutition became easy. Patient 
spoke, and said that he felt relieved. 

Patient continued quite comfortable till half past two P. M., when I was 
again called. I found him suffering under severe tetanic convulsions ; muscles 



76 Clarke, Traumatic Tetanus treated with Chloroform. [July 

of the neck, jaws, and throat, were rigid; mouth opened with difficulty; de- 
glutition impossible ; attempts to swallow produced convulsions, which almost 
threw the patient from his bed ; severe pains in left side, which appeared and 
disappeared in paroxysms ; extensors of legs, feet, and toes, contracted ; muscles 
of arms rigid. Every three or four minutes, opisthotonos so violent that the 
pelvis was raised from the bed, and the body arched. Sometimes the elbows 
would be suddenly pushed into the bed, the pelvis raised, the head drawn back, 
the heels forced down, and the body supported in this position for two or three 
seconds. The patient would then fall back exhausted, and without full relaxa- 
tion of the muscular system. The convulsions recurred about once in three 
minutes. Pulse 120, feeble ; respiration 48, of a jerking character, each in- 
spiration being succeeded by a sudden and broken expiration. Brows con- 
tracted j eyes fixed and staring, and corners of the mouth drawn down. The 
mental faculties of the patient were undisturbed. The wound upon his thumb 
was slightly red and swollen j a poultice, with laudanum, was applied to it, 
and a bottle of chloroform sent for. 

Inhalation was commenced at three P. M. No inhaler was used. Chloro- 
form was administered by means of a pledget of cotton in a handkerchief. 
After a few struggles, patient came fairly under its influence. The first spasm 
was sensibly mitigated in violence, and followed by an interval of quiet for ten 
minutes. At four, one hour from the commencement of inhalation, the fourth 
spasm occurred, which was not violent enough to raise any part of the body 
from the bed. Pulse, then, 88 ; respiration 28. It was decided in consulta- 
tion to continue inhalation uninterruptedly for a considerable time.* This I 
was enabled to do by the assistance of several physicians, Drs. Buckingham, 
Andrews, Stone, Thayer, Mr. Ellis, &c. ; a medical attendant was constantly 
in the room, who kept his finger upon the patient's pulse. 

The following notes will give an idea of his condition during inhalation : — 
4 J P. M. A slight jerking or twitching of the body. Muscular system 
fully relaxed. Limbs, when raised, fall easily back upon the bed. Head can 
be easily moved. 

9 J P. M. Pulse 88 ; respiration 28, natural. Muscular system is and has 
continued to be fully relaxed. The pulse has not varied more than four beats 
from 88, nor the respiration more than two from 28. The patient has been 
kept in a state of incipient stertor. The pulse has been taken as a guide for 
increasing or diminishing the amount of vapour. Whenever the chloroform 
has evaporated or been removed, the pulse has risen, and upon renewing the 
supply, it has fallen. Patient has just vomited. 

10^ P-M. Patient has again vomited; rouses, speaks, and complains of 
bitter taste in his mouth ; calls for water, which he drinks with ease ; pulse 
88 ; respiration 28. 

March 6th. 7 J A. M. Inhalation has been continued constantly during the 
night. No return of spasms. Has passed water once, freely. Has drunk tea 
and water several times without difficulty or convulsion. Has had occasional 
nausea, but no emesis. Pulse has been kept within four or five beats of 70. 
Respiration has been 20; pulse now 68, feeble; respiration 20. Answers 
when addressed, and says he feels feeble. Looks around, speaks, moves limbs, 
and changes position naturally and without spasm. Countenance less anxious, 
and brow less contracted. Continue poultices to wound. 

10 A. M. Still under influence of chloroform. Has drunk some tea and 
vomited ; vomiting followed by copious perspiration ; passed urine once since 
7j; pulse 72, respiration 20. Begs to have inhalation stopped. 

* Drs. Bowditch, Perry, Gay, and others, saw the patient in consultation. 



1849.] Clarke, Traumatic Tetanus treated icith Chloroform. 77 

I P. M. Apparently asleep ; no return of spasms ; pulse 68 ; respiration 20 j 
vomited once slightly since 10 A. M.; has taken wine and water and sago 
gruel in small quantities. 

4 P. M. Inhalation has been continued twenty-five hours, uninterruptedly ; 
pulse 70; respiration 20 ; no return of spasms; no rigidity of muscular system; 
no contractions excited by movement. Directed room to be kept perfectly 
quiet, and inhalation to be discontinued. 

6 P. M. No return of convulsions; has complained of heat and pain in head, 
and desired to have it bathed, which was done; pulse 84, feeble; respiration 
19; countenance natural; tongue cleaning at edges; deglutition easy; no stiff- 
ness about neck; has a sensation of "soreness" along back, but no pains. 

8 P. M. Pulse and respiration same; is restless and uneasy; directed room 
to be kept dark and quiet, arrow-root and gruel to be given when thirsty, a 
tablespoonful of camphor water, pro re natd, and every four hours a mixture 
of chloroform, Hoffmann's anodyne and camphor. 

March 7th. 8 A. M. Vomited after first dose of mixture, and refused to 
take any more; got camphor water occasionally during night; except a restless 
hour at midnight, slept comfortably; has had one dejection, dark and very 
offensive; no return of spasm; pulse 72, soft and feeble; respiration 20; 
countenance natural; tongue cleaning; extremities warm; omit mixture, but 
continue camphor, and may have beef tea and arrow-root. 

II \ A. M. Called to patient on account of a short, catching, and frequent 
cough, attended with pain at lower end of sternum ; cough has a sharp and 
stridulous sound; thinks he feels some stiffness about neck, but says that it 
may be fancy; has had another dejection, dark and offensive; pulse 76, fuller 
than at eight ; respiration 21 ; directed a mixture of Hoffmann's anodyne and 
camphor in syr. tolut. every second hour, with beef tea and arrow-root. 

3 \ P. M. Grot mixture once and vomited it ; refused to take any more ; cough 
gone; no pains at sternum; occasional eructations; pulse 80, soft; respiration 
20. Omit all medicine and continue nourishment ; take beef tea, wine, and 
gruel. 

8 P.M. Asleep; skin moist; pulse 68; respiration 20; bladder has been 
freely emptied during day ; less restless ; doing well. 

March 8th. 3 A. M. Called to patient on account of severe pain along- 
upper two-thirds of sternum; no pain elsewhere; pulse 78, soft; respiration 
24 to 26; has had another copious dejection, offensive; has occasional eructa- 
tions, followed by momentary relief of pain ; no stiffness about neck or jaws ; 
deglutition easy ; gave some beef tea, with wine and camphor, and dose of 
above mixture ; patient seemed somewhat relieved, and I left him, with a pulse 
of 78 and respiration of 20. 

7 A. M. Called again ; patient was easy at intervals from three to six o'clock ; 
since six has been suffering from continued pain along length and at lower end 
of sternum ; paroxysms of increased suffering, with contractions of the pectoral 
muscles, occur every three or four minutes ; is supported in an upright position, 
cannot lie down ; has an occasional stridulous cough ; tone of voice altered ; 
sensation of stiffness in the jaws; slight tenesmus, but no dejection; brows 
contracted and countenance anxious ; patient is fearful of the result ; pulse 84 ; 
respiration 44, jerking; expiration short and sudden, as if there were an ob- 
stacle to the contraction of the chest ; no marked spasms or decided muscular 
rigidity; chloroform was again administered by inhalation. 

1\ A. M. Some stertor; pulse 68; respiration 20, with full and natural 
movement ; decubitus dorsal ; muscular system relaxed ; no rigidity about chest 
or neck ; the inhalation was conducted as before, by means of a pledget of 
No. XXXV.— July, 1849. 6 



78 Clarke, Traumatic Tetanus treated with Chloroform. [July 

cotton in a handkerchief. Whenever the pulse rose, the chloroform was applied 
more closely to the nostrils ; when it began to sink, more atmospheric air was 
admitted. The following table exhibits the condition of the pulse and respira- 
tion during the second period of inhalation : — 

Hour. Pulse. Resp. 

o 1 ^ q-i (Is quiet; muscular system relaxed ; brow uncon- 

* ( tracted ; countenance natural. 

9 68 28 Chloroform freshly applied. 

9 J 84 36 Chloroform nearly out ; is uneasy. 

q a £p »r> J Chloroform freshly applied ten minutes since; 

4 1 slight rigidity of flexors of forearm. 

10 80 44 
10i 80 28 

10* 80 28 Slight stertor. 
lOf 84 31 Slight stertor. 

-. -. rw 98 J -^ ve mmutes before 11, turned over, said we could 

\ not cure him ; he was in too much pain. 

11 \ 88 36 Drank some tea. 
11* 80 24 

llf 80 32 

12 84 34 
12| 80 30 
12* 84 34 
12f 88 36 

1 84 28 Asleep; chloroform removed. 

\\ 84 28 m 

1* 96 31 Still quiet. 

Directed room to be kept quiet, and wine and beef tea to be given, or broth, 
every hour. 

3 P. M. Pulse 80; respiration 28; asleep, no return of spasms. 

11 P. M. Is quite comfortable; has taken beef tea or wine every hour; no 
pain, no rigidity, no spasms. 

March 9th. 8* A. M. Has slept well; feels no pain, countenance natural, 
tongue clean ; wound on thumb looks well; pulse 56 ; respiration 19 ; directed 
to take broth, beef tea, and wine, pro re natd; no medicine. 

6 P. M. Pulse 72 ; respiration 18; appetite good; no pain, asks to sit up. 

March 10. Still convalescent. 

March 11. Walks about; has eaten beef-steak. 

March 12. Wound on thumb healed; discharged well. 

April 4. Mr. D. L called at my office ; has been at work ; is well. 

This case is interesting not only on account of the immediate alleviation of 
the tetanic symptoms, which followed the administration of chloroform, but 
also on account of the slight general disturbance which followed such a pro- 
longed inhalation. Inhalation was continued uninterruptedly for twenty-five 
hours. During much of this period there was slight stertor, but not always 
entire unconsciousness. After an interval of forty hours, inhalation was re- 
commenced and continued for six additional hours. No perceptible ill effects 
followed this prolonged inhalation. 

It is worthy of remark, that in this case nothing but chloroform and nour- 



1849.] Jackson on Tea and Ooffee. 79 

ishment was given. Neither opium, mercury, nor antimonials, were employed. 
The credit of the cure belongs either to chloroform, or nature. In ascribing it 
to the former as much as to the latter, I shall scarcely be accused of reasoning 
post, ergo propter hoc. 



Art. IX. — On the Influence upon Health, of the Introduction of Tea and Coffee 
in large proportion into the Dietary of Children and the Labouring Classes. 
By Samuel Jackson, M. D., Professor of the Institutes of Medicine in 
the University of Pennsylvania. 

Tea and coffee enter more largely into the diet of the people of this country 
than into that of any other. The ordinary breakfast and supper of thousands 
of persons in every part of the United States, are tea, coffee, and bread; while 
tea, bread, and potatoes, with occasionally a modicum of meat, constitute their 
dinner. Even children, as soon as they are able to sit at meals, are habitually 
placed at the family table, and allowed to partake of the same food as adults. 

In the poorer classes, the evil of a common diet for all ages cannot probably 
be avoided. It is one of the causes productive of the greater mortality of the 
children of the poor. But this injurious practice, which with the poor is to 
be regarded as an inevitable misfortune, is followed by those who are placed 
in circumstances above the necessity of it. In them it is most condemnable, 
and can be excused only on the plea of ignorance. 

The classes in which the kind of alimentation alluded to prevails, are female 
teachers, seamstresses, factory women, weavers, tradesmen, small retailers, 
clerks with families, and others living on restricted means, and very generally 
farmers in the country. 

The inducement for its adoption is its economy, as to money, time, and fuel 
— a meal of coffee, or tea and bread, or the addition of potatoes, for a small 
family, will not cost beyond a few cents, while it requires but little fuel and a 
very short time for its preparation. Tea and coffee are, besides, very palatable, 
produce temporary exhilaration and force, and abate hunger. Coffee, as will 
be shown, is not devoid of some nutritive properties. Ostensibly answering, 
in this manner, the purposes of food, tea and coffee have, from the considera- 
tions of cheapness and convenience, become the substitutes of more substantial 
diet. 

In this country and England, chiefly, tea and coffee are introduced into the 
daily meals as aliment. In China, tea is used as a refreshing and cordial beve- 
rage, presented to visitors, or drunk between meals; in the East, coffee is re- 
garded in the same light, and employed in the same manner; on the continent 
of Europe, coffee is extensively used, but more as a cordial drink, or to flavour 
cream and milk, than as aliment. 



80 Jackson on Tea and Coffee. [July 

In prosecuting this inquiry with a view to the effects on the economy, of tea 
and coffee, some preliminary matters require previous examination. 

Every one knows that food is indispensable to life. But what is this con- 
nection between them ? How is it that food is an indispensable condition of 
life ? The solution of these questions is necessary to the understanding of the 
nature and objects of food, to determine the value of any alimentary articles, 
and to settle the pretensions of any substance for a place in the category of 
food. 

Before examining the relation existing between food and life-action, it is 
important to obtain an accurate idea of what is life, or organic action. This 
term we limit to a single series or class of phenomena. These phenomena are 
the evolution or production of specific organizable matter and definite organic 
forms, from a primary formless organic substance. Albumen is that substance 
in man and the higher animals. All other phenomena are excluded. They 
are subordinate to, depend on, but are indispensable to maintain life-action. 

Organized tissues and organs worked out by life-action, are the instruments 
of life. They differ widely from each other. Each has its special office. 
The phenomena of each are special in character and purposes. They are the 
same as similar phenomena in the exterior and inorganic world. They can 
be properly understood and studied only in their connection with those phe- 
nomena. Some are chemical, as the transformation of albumen, the processes 
of digestion, secretion, and the oxidation of carbon and hydrogen in the blood 
producing animal heat. Others are physical, as the capillarity of tissues, im- 
bibition, endosmose, atmospheric pressure, and Graham's law of the diffusion 
of gases, in respiration ; others are dynamic, as the excitor, motor, and other 
forces of the nervous system ; others, again, are purely mechanical, as the 
actions of the muscular system. 

Not one of those is properly an organic or life-phenomenon. They are in- 
dispensable to maintain the condition of the existence of life, or organic action. 
They are chemical, physical, dynamic, and mechanical actions, executed by 
organized and living apparatus and instruments, for the objects of life. 

The organizable matter and organic forms are the products, and, conse- 
quently, the expression of existing forces or causes of action. Forces, matter, 
and form, are indissolubly connected with, and give rise to, phenomena or 
function j and, inversely, function and phenomena are the correlatives of force, 
matter, and form. Organized matter, from its nature, cannot be persistent. 
Under normal states, force, matter, form, and function or phenomena, are 
permanent; but the structural material itself is not permanent — it wastes, 
decays, disintegrates, and is reproduced in every act of life. Life-action is 
thus resolvable into two inseparable actions, or links of one action, a birth 
and a death, the formation and destruction of the organic material of our 
structure. 

The supply of the primary organic substance for this incessant renewal and 
building up of the organized structure and maintenance of organic forms, is 



1849.] Jackson on Tea and Coffee. 81 

derived from the blood. This fluid, in its natural state, is a concentrated 
solution of all the solids and products of the animal economy. The amount 
of azotized or albuminous compound matter destroyed in twenty-four hours by 
life, or organic action, may be taken, on an average, at two to three ounces.* 
The blood would rapidly become impoverished and unfitted for life objects, 
unless its losses of albumen and its organic derivatives were constantly re- 
stored. The renewal of the organizable or plastic material of the blood, and 
its maintenance in its normal composition, for structural formation, is one of 
the offices of our food. Repeated analyses have demonstrated that, of the 
aliment that is adapted to healthy nutrition, one-eighth part only consists of 
albumen, or its protein compounds, or their derivative compounds ; and what- 
ever is devoid of those substances — that is, the chemical combination of car- 
bon, hydrogen, nitrogen, and oxygen, in the proportion to constitute protein 
(C 40 H 30 N 5 O 13 f) or albuminous compounds — cannot perform the office of food, 
or be fitted for nutrition. 

Another condition, not less indispensable to life-action, than organizable or 
plastic matter in the blood, is a definite temperature. For man and the 
warm blooded animals, the heat essential to healthy, vigorous life-action is 98° 
to 100° F. So important is heat to life, that nature has made provision for 
its constant disengagement in the economy. This is accomplished by the 
incessant oxidation of carbon and hydrogen in the blood. The temperature 
of this fluid is thus kept at an equable point in every part of the economy. 
Every organized molecule requires, for the exciting and sustaining of its life- 
action, the presence of plastic or organizable material, and a definite tem- 
perature. 

The blood furnishes both these indispensable conditions of life-action to 
each living molecule. 

The carbon and hydrogen oxidized in the blood, and in this manner gene- 
rating animal heat, are obtained from the food. Nature has made most ample 
provision for the supplies of these chemical elements, by constituting them a 
large portion of the food of animals. Not less than from six-sevenths to 
seven-eighths of the alimentary substances of animals consist of non-azotized 
bodies. Fatty, starchy, and saccharine matters, are of this character; they 
are not adapted to or intended for nutrition, but solely for the purpose of 
calorification, by their combustion or combination with oxygen introduced 
into the blood by the processes of respiration. This proposition is demon- 
strated in the composition of the alimentary portion of milk. The casein or 
plastic matter for nutrition, averages 13 per cent., the calorifacient, or the 
cream and sugar of milk, 87 per cent. 

Temperature is required not only for life-action, but also for the dynamic 
forces, and mechanic power and actions seated in and performed by the mus- 
cular apparatus. 

* Dumas, Chimie Physiologique et Medical, p. 463. 
f Mulder. 



82 Jackson on Tea and Coffee. [July 

The identity of heat and mechanic force has been established by M. Joule.* 
It is expressed in the following formula: the heat required to raise one 
gramme (15 grains) of water one degree (cent.), is capable of raising 432 
grammes (3700 grains) one metre, or 3^ feet. 

According to the estimate of Dumas, the quantity of carbon consumed by 
a man in good health (valuing the hydrogen by an equivalent proportion of 
carbon), averages from seventeen to twenty-eight ounces per diem. The large 
amount of heat thus disengaged, is the sum of the dynamic or excito-motor 
force of the nervous system. 

By the establishment of the above facts, we obtain precise ideas of the na- 
ture of food, its objects in the economy, and the modes of its operation. We 
are enabled to say with certainty what substances are or are not food ; and to 
fix the relative value of each article of diet. 

From these investigations, it is ascertained that alimentary substances form 
two distinct classes, differing from each other by the most striking diversities 
of nature, composition, and operation. 

The first class are the protein or albuminous compounds. They have nearly 
the same chemical composition as the tissues, are isomeric with many of the 
immediate organizable materials of animal structure, and are exclusively des- 
tined to nutrition proper, or the reconstruction and repair of the solids. 

No substance in which this especial chemical composition, protein and its 
compounds do not exist, can belong to this class, or can be employed in the 
economy for its nutrition. Some of the most eminent organic chemists and 
physiologists appear to suppose, that any organic nitrogenized body may answer 
for nutrition. This is not so. Morphia, quinia, strychnia, urea, taurine, as 
well as theine, and caffeine, are organic nitrogenized bodies, yet cannot be 
ranked as food. It is the possession of the specific combination of which 
protein is the base, that can alone entitle any substance to rank in this class. 

The second or calorifacient class of aliment, comprehends those special che- 
mical compounds, hydro-carbons mostly, that are capable of prompt decom- 
position into carbon and hydrogen in the blood. No other organic substances, 
though rich in carbon and hydrogen, are capable of entering into this division 
of aliments. 

The normal substances of this kind are glucose and lactic acid, into which 
saccharine and amylaceous substances are converted by the process of sali- 
vary digestion; and fatty matters, modified and reduced to the finest and 
minutest particles possible, in the emulsion formed with them by the pan- 
creatic and biliary secretions. 

This last class is the more immediately connected with the maintenance of 
life. It is established by the experiment of Chossat,f that death from starva- 
tion does not occur from inanition, or the waste of the organs, but from the 

* Comptes Rendus, tome xxv. p. 209. 

j" Recherches Experimentales sur l'lnanition, Paris, 1843. 



1849.] Jackson on Tea and Coffee. 83 

cooling of the blood, from the absence of the carbon and hydrogen requisite 
to carry on the process of combustion and the generation of caloric. 

With the preceding facts ascertained, we can now proceed to investigate the 
claims of tea and coffee, to be regarded as properly belonging to either of the 
above classes of food. 

Theine and caffeine, according to Liebig, are the essential elements of tea 
and coffee. The two are identical as to chemical equivalents. The formula 
for each is C 8 ,II 5 ,N 2 ,0 3 . M. Payen, in a later and more elaborate examina- 
tion, gives a somewhat different formula, but not such as to vary their proper- 
ties to any extent. Liebig considers them as closely approximating to alloxan, 
C g ,H 4 ,N 2 ,0 1 , a principle obtained from urea, by the action of concentrated 
nitric acid; and to taurine (C 4 ,H 8 ,N0 10 ), a principle which may be obtained 
from ox bile, but not from human bile. 

In this view, tea and coffee must be excluded wholly from the classes of ali- 
ments, to which theine and caffeine can have no pretensions. 

But M. Payen, in 1846, in a communication to the Academie des Sci- 
ences,* presented a highly laboured and accurate examination of the proximate 
constituents of coffee, which unquestionably brings it, at least, into the cate- 
gory of aliments, as it contains the constituents of both classes. 
The following is his analysis of coffee :f 

Cellulose - 34 

Fat substances - - - - -10 to 13 
Glucose, dextrine, and an indeterminate vege- 
table acid - 15.5 

Legumin, casein (gluten) - - - - 10 

Chloroginate of caffeine and potassa - 3.5 to 5 

Azotized organic matter 3 

Free caffeine 0.8 

Insoluble concrete vegetable oil - - - 0.001 

Fluid aromatic essence of sweet odour, and a 

less soluble acrid aroma - - - - 0.002 

Mineral substances, potassa, lime, magnesia, 
phosphoric, sulphuric, silicic acids, and a 
trace of chlorine - - - - - '6.697 

Water -------- 12 



100 
From this composition of coffee, it is evident the grain is endued with 
nutrient or plastic and calorifacient elements, and, consequently, is an ali- 
ment ; yet the proportion of those elements is not sufficient to place it in a 

* Comptes Renders, tomes xxii., xxiii., 184G. 
-j- Comptes Rendus. Tome xxiii., f. 249. 



84 Jackson on Tea and Coffee. [July 

high rank in either class, or to justify the substitution of its infusion as a chief 
material of food, by those who are engaged in active and laborious pursuits. 

But when the quality of the weak infusion almost generally used as food, 
and the consequent very small proportions of the alimentary elements held in 
solution in it are taken into consideration, the disparity between the waste of 
the blood and the elements for its reparation contained in coffee, become strik- 
ingly displayed. The ordinary coffee of the laboring and industrious classes, 
is little more than warm water colored and aromatized by coffee. It contains 
but a very small portion, if any, of the nutritive and calorifacient elements. 
It is impossible, with such diet, to maintain in the blood the two indispensable 
conditions of life-action and nerve-force, organizable material and heat. 

Coffee, to be prepared as food, should be first but slightly roasted, merely 
browned and rendered crisp, so as to be easily reduced to a coarse powder. 
A concentrated infusion is then to be made by the process of displacement, 
There should be added to it an equal, or double its quantity of cream or good 
milk, and be sweetened with sugar. An alimentary drink is thus prepared, 
possessing all the requisites of good food, with the addition of a specific ex- 
citant action on the nervous system and brain, that entitles coffee to the 
appellation bestowed on it by Rousseau, u boisson intellectuelle." 

The ordinary miserable preparation of coffee so extensively used as food, 
deficient in proper alimentary principles, by taking away appetite, by distend- 
ing the stomach with a warm liquid, and thus impairing its digestive power, 
and by its agreeable aroma corrupting the taste, rendering more nutritious 
food unpalatable, tends to the ultimate impoverishment of the blood. This 
fluid loses its proper character, that of a concentrated solution of all the 
organic elements and products of the economy. 

As a consequence of this condition of the blood, the waste of the tissues 
exceeds the repair, death-action is stronger than birth-action ; disintegration 
of structure predominates over its reformation. In time this loss of balance 
tells : the organs are degraded from their primitive type ; their functions 
are impaired, and the organism descends in the scale of development. There 
is an approach to inferior organisms, and to cold blooded animals ; or, rather, 
the system is kept permanently in what constitutes the cold stage, or tendency 
to collapse in febrile diseases. 

In this state, individuals suffer from a variety of vague anomalous symp- 
toms, characterizing no definite disease. They are always ailing, complain- 
ing, suffering, but not absolutely sick, They are miserable themselves, a 
plague to doctors, the prey and victims of quacks. 

In this condition of the economy, the temperature is low. Dynamic force, 
which is identical with heat, is equally depressed; and, consequently, the 
mechanic or muscular power is at zero, and the offices of the economy depend- 
ing on it are imperfectly performed. The circulation is feeble, digestive 
movements slow and defective; languor and exhaustion prevail. Exercise 
augments the evils by expending the forces more rapidly than produced, and 



1849.] Jackson on Tea and Coffee. 85 

the nervous functions are in a state of perturbation or depression. These 
disordered states are the results of a slow inanition or starvation, not sus- 
pected, because food is taken to the full repletion of the stomach ; yet still it 
is starvation, for the blood does not possess the elements for heat and nutri- 
tion adequate to the full energy and the consumption of life-action. These 
cases are not remediable by medicine j they can be relieved only by a restora- 
tion of the digestive functions, and a return to a wholesome and appropriate 
diet. 

Cases of this character have augmented in our towns and cities, and it is be- 
lieved in the country, particularly amongst women, and in the industrious and 
labouring classes, in the last ten or fifteen years most rapidly. The neuroses, 
as gastralgia, different visceralgias, and other forms of neuralgia, are now 
quite as common amongst those classes, if not more so, than they were for- 
merly amongst the luxurious and idle, to which they were almost exclusively 
confined. 

A suspicion has arisen that this circumstance is to be attributed to the per- 
version of the use, as food, of tea and coffee, from their proper employment as 
nervous excitants and cordials, which are their appropriate properties. On in- 
quiry it is almost uniformly found, at least, in the observations of many 
medical practitioners, that the greatest sufferers from these disordered states, 
are the inconsiderate consumers of tea and coffee, who substitute them largely 
for food. 

It would extend this inquiry too far to enforce the above views by relations 
of specific cases. A large number could be cited as strongly illustrating their 
correctness. 

The practice of giving tea and coffee to children at their meals cannot be 
too strongly reprehended and discountenanced. In the first periods of life, 
the most nutritive food, rich in plastic elements and capable of favoring the 
highest organization, is that which is required for growth and development. 
In the first fifteen years, nature is employed in constructing and perfecting the 
mechanism of life, fitting it for the conflicts, the exertions, the labours it 
must encounter and undergo in the struggles and difficulties of the great arena 
of the world, as well as with exterior malignant influences hostile to its exist- 
ence, to which it is incessantly exposed. Without good materials there can- 
not be produced a good fabric. 

Whatever tends to excite, to render irritable, or to develop unduly the cere- 
bral structure and functions in children, is of necessity injurious. The bills 
of mortality show the fearful ravages in the early years of life from cerebral 
disease j and the foundation of most of the neurotic diseases and of ill-health 
in adult life, dates from the abortive efforts of nature to build up substantial 
organs from the paucity and poverty of the building materials, or the abnor- 
mal direction imparted to nutritive action, by over excitement, in the com- 
mencement of development. 

Tea and coffee being cerebral excitants cannot act otherwise than injuriously 



86 Trask's Surgical Cases. [July 

en children, in whom there exists no object for such artificial stimulation. 
Indirectly, they are mischievous by taking the place of food that contains all 
the elements and constituents of the fluids and solids of the organs and their 
products. They should be abolished from the dietary of children in all well- 
regulated families, and by parents careful of their childrens' welfare. 

The analysis of tea is not complete, like that of coffee, by M. P&yen. As 
far as known, it contains no alimentary elements, and cannot be classed with 
food. It is a purely cerebral excitant. 

Though the grain of coffee has amongst its constituents alimentary ele- 
ments, yet in the common slovenly process of torrefaction, the calorifacient 
principles are destroyed; and the plastic are also ;more or less decomposed. 
But when more carefully performed, and these principles are not materially 
injured, still a small portion only can be dissolved in the infusion or decoction 
made in the ordinary mode. 

The infusions of tea and coffee cannot, therefore, be used as food, and be 
made substitutes for nutritious aliment, without a serious detriment to the 
economy. They are cordial beverages, and as such are grateful and useful, 
especially to those engaged in mental pursuits, and who lead sedentary lives. 
They must, at the same time, be combined with substantial nutriment, or the 
blood becomes impoverished, and fails to contain the materials for organic 
structure, evolution of nerve-force. 

In proportion to the degree of physical exertions, are the wear and tear of 
the solids, and the expenditure of the forces. The elements to maintain 
these in their normal conditions, must exist in the blood, and the blood ob- 
tains them from the aliment in which they exist, through the digestive appa- 
ratus. Tea and coffee largely drunk at their meals by those engaged in active 
and laborious pursuits, by excluding a due quantity of substantial food, rich 
in the plastic and force-producing elements, are more injurious to these classes 
than to the sedentary. 

The inevitable consequences of this practice must be to undermine the 
constitution, to impair the health, to break down the forces, to cause various 
nervous sufferings, and finally to produce disability for labour. 



Art. X. — Surgical Cases. By James D. Trask, M. D., Whiteplains, West- 
chester County, New York. 

Case I. — Erectile Tumour, Ligature of the Primitive Carotid. — In the 
spring of 1847, while visiting a patient, my attention was accidentally arrested 
by a young woman, whose countenance presented a shocking deformity. On 
examination, an erectile tumour was ascertained to occupy nearly the whole of 
one side of the face. Her friends stated, that at birth there was a coloured 
spot just above the angle of the mouth, and another just below and outside 



1849.] Trask's Surgical Cases. 87 

the external angle of the eye of the same side, neither being larger than a 
small pea. These soon commenced to encroach upon the healthy portions of 
the cheek, until the disease, in a great measure, supplanted the original tissue. 

She was about thirty years of age. The disease had not advanced for 
several years, and her condition was as follows. The entire right side of the 
face, below the eye, was enlarged; the surface of a dingy yellow, with bluish 
spots (her complexion being sallow), bosselated, with here and there a promi- 
nence of a deeper blue from a greater supply of blood-vessels. At two or 
three spots there appeared to be no other covering to the blood-vessels than 
smooth shining cuticle. The most curious feature, was the upper lip, the right 
half of which was so immensely enlarged, as to hang down and completely 
conceal the mouth and chin, when viewed from that side, and to project in 
front of the lower lip. The disease extended just up to the mesial line of the 
lip, and there suddenly stopped. The right half thus enlarged measured three 
and three-fourth inches in length, and two inches in thickness ; it hung down 
like an apron over the mouth, and required to be raised with one hand, while 
food was introduced into the mouth by the other. The mucous membrane 
was beautifully mottled by the natural pink and the blue of the adventitious 
vessels. The whole substance of the cheek was implicated, from the cuticle 
to the mucous membrane lining it. The disease invaded the lower eyelid and 
the conjunctiva of the eye, and was bounded by the margin of the hair at the 
temple, by the external ear, the ramus and lower margin of the jaw and the 
nose, of which the right ala was dragged down out of its place. Pressure upon 
any portion diminished the tumour in a certain degree, but the lip could be 
completely emptied, after the manner of a sponge, and was then reduced to a 
shrivelled mass of loose tissues, ready to fill up immediately upon the relief 
of pressure. This she could effect by a suction of the lip against the teeth 
aided by the hand. 

No pulsation could be detected in any part of the tumour, except that of the 
coronary artery, which was rather larger than in the opposite side ; neither 
could any enlarged vessels be found at the margin running into its substance. 
Nor was there any whizzing or vibratory feel communicated to the finger. 
The size of the tumour was always increased under excitement, either mental 
or physical, and especially at each menstrual period. Whenever this happened 
there was an increase of severe pain in the cheek, apparently neuralgic, from 
which she was rarely free. Long-continued pressure of the tumour had nearly 
destroyed the natural curve of both jaws on the right side, so that, from the 
mesial line backward, both were flattened in their whole extent. The disease 
extended to the base of the alveolar ridge, but she had had two teeth extracted 
without any alarming hemorrhage. On two occasions there had been free 
hemorrhage from the cheek, which was arrested with considerable difficulty ; 
in one caused by a prick of a needle. No attempt had ever been made to 
arrest the progress, or to remove this disease, and she anxiously inquired if 
anything could be done. 

So great was the extent of the disease, that no mode of treatment gave any 
hope of success, while the supply of blood still continued uninterrupted. She 
was told that the operation of ligating the main vessel, leading to the tumour 
had been done, and sometimes with success ; but that hers was not a favour- 
able case, inasmuch as it appeared to be chiefly venous in its structure, and 
also that the operation was attended with considerable danger to life. At her 
earnest request I performed the operation of ligating the primitive carotid of the 
right side, on the 8th of April, in the presence of Dr. A. C. Post, of New York> 
and of several other professional friends. The sheath was opened, and the 



88 Trask's Surgical Cases. [July 

ligature placed in the artery, without exposing the vein or the descendens noni. 
Immediately upon tightening the ligature a strong pulsation was felt on press- 
ing the distal portion of the artery toward the spine. When lifted up from the 
surrounding parts it ceased, and was due to a large artery, running directly 
in the course of the carotid and behind it. In the evening she was excited 
and restless, and complained of violent throbbing at the point where the liga- 
ture was applied, and of pain about the top of the head. There was a good 
deal of nervous excitement, and she was light-headed; saw horses, &c; pulse 
84, soft and natural. Ordered pills of hyoscyamus and assafoetida. 

April 9th. Passed a comfortable night; had considerable thirst, and pulse 
rose to 105 in the evening. 

10th. Was rather restless and somewhat delirious, expression of counte- 
nance, ill tempered ; complained a good deal of difficulty of swallowing. Her 
courses, which had appeared on the 5th and disappeared before the operation, 
reappeared ; tumour became larger than usual. 

12th. My friend Dr. Brown detected retrograde pulsations in the right tem- 
poral artery ; still suffered from menorrhagia, for which she had been taking 
acet. plumbi and opium. 

14$.. For two or three days memory had been impaired; forgot when the 
operation was done, and when her friends called to see her ; had some pain 
about the temples ; tumour painful to the touch, and colder than the rest of 
the face ; but not more sensitive or cold, than often before the operation. 

17th. Still sees bugs, &c, when she looks steadily. Pulsation felt to within 
an inch of the ligature. 

The wound was not entirely healed for a month, at the expiration of which 
time, all evidence of cerebral disturbance disappeared, and memory was re- 
stored. The ligature came away on the sixteenth day; no part of the wound 
healed by the first intention. 

At times she fancied the tumour diminished in size, but it soon became 
evident that no permanent change had taken place. Her health was so deli- 
cate as to forbid any farther proceedings at that time. 

June 4:t?i. With the assistance of my friends Drs. Brown and Ayres, I passed 
thirty needles, heated to a red heat, through the substance of the left half of 
the diseased portion of the lip ; thrusting them in various directions, so as to 
excite inflammation in the whole of that part. Considerable hemorrhage 
followed one or two of the punctures, which required nit. arg. to suppress it. 
A lead plate was then applied, which had been previously prepared, by cutting 
it from a piece of sheet lead, of such a shape, that, when turned over upon 
itself, it could be exactly applied to the upper and under sides of the lip, so 
that, when squeezed between the thumb and finger, it compressed the lip thus 
embraced. It was covered with cotton flannel, on both sides, and suspended 
by strings attached at either end, tied over the top of the head. Scarce any 
inconvenience was experienced from the lip, and no febrile excitement. 

6th. The lip being rather painful, the lead was taken off, and the lip imme- 
diately filled up, and recovered its original size; the sloughs were separating 
from the needle-holes. The lead was reapplied ; she had nervous chills after- 
ward. 

7 th. The lead plate was replaced by one of thin tinned iron, which was 
. lighter; the lip filled up as before; it felt harder, and could not be compressed 
to the same degree as before. 

9th. Had considerable pain in the lip, and headache; was thirsty; the pulse 
fuller; courses had come on the preceding night; was very nervous; but little 
pain in the lip; had had no alv. deject, for two days; all the disturbance ceased 



1849.] Trask's Surgical Cases. 89 

after the operation of a laxative. The tin clamp was removed, as the wounds 
were nearly healed. Some indurated spots could be felt for some time after- 
ward, which were subsequently absorbed, and the lip remained as it was before 
the ligature of the artery. My removal from Brooklyn prevented any farther 
attempts to relieve her. 

The above was a case of erectile tumour of unusual extent, and involved im- 
portant parts. In structure it was evidently chiefly venous. There was an 
absence of pulsation and vibratory thrill, both in the substance of the tumour 
and at its circumference, which is perceived when the arterial vessels form a 
prominent part of the diseased structure. The coronary artery was enlarged, 
but its pulsations were communicated to none of its subdivisions, neither could 
any enlarged veins be traced from it. 

The cure of the disease was desirable, not only from the deformity, which 
unfitted her for society, and its extreme inconvenience, but from the risk of 
severe hemorrhage from accidental injuries, as well as ulceration of the surface 
lying in contact with the teeth. In considering the possibility of affording re- 
lief, three prominent plans suggested themselves ; first, removal of the diseased 
mass by excision or ligature, second, the induction of adhesive inflammation, 
by setons, needles, &c, and third, ligating the principal vessels leading to the 
parts. The first appeared to be out of the question, from the impossibility of 
removing a large portion of the disease without destroying the side of the face; 
and though the enlarged lip could have been removed, dangerous constitutional 
irritation was apprehended from the ligature, and uncontrollable hemorrhage 
from the knife. The fact of the size of the tumour being affected very mate- 
rially by the state of the circulation, was the principal reason for rejecting the 
second, and resorting to the third mode. And yet the experience of others 
afforded but little encouragement for the trial of the ligature of the principal 
arterial trunk. Ligature of the carotid failing to effect anything, it was re- 
solved to make trial of heated needles, and thirty were introduced. 

It had occurred to me, that if by any means compression could be made, 
upon the part operated upon, sufficient to keep out of it the adventitious blood 
contained in the cells, and which is to be regarded as accidental, and at the 
same time allow the entrance of a sufficient quantity to support the vitality of 
the parts, something important would be gained. The blood contained in the 
cells coagulates on the introduction of the heated needles, and then becomes a 
foreign body, which must subsequently be removed by absorption; its presence 
sometimes producing excessive inflammation, ending in sloughing, with no 
little risk to the patient. But if the cells should be first emptied of blood, on 
the effusion of lymph, their parietes would become agglutinated; and, the 
pressure being removed, the tumour remain shrivelled, the cellular structure 
having been destroyed; there still being a sufficient supply of blood to subserve 
the purposes of nutrition. If I am not mistaken, this combination of com- 
pression and the use of the needles, may be rendered available in the treatment 
of many cases of this disease. In the one above related, the needles failed to 



90 Trask's Surgical Cases. [July- 

kindle the desired amount of inflammation, but, so far as it goes, that trial 
would encourage a similar resort to the co-employment of compression. 

Of course, various contrivances will be required, according to the situation 
of the tumour. The one adopted in our case was suggested by my friend Dr. 
W. K. Brown, of Brooklyn, and was completely adapted to it, and most per- 
fectly simple. In other situations I should be disposed to try an application 
of compressed sponge, as recommended by Dr. J. K. Batchelder, of New York. 
A piece adapted to the figure of the part is closely bound on by adhesive strap 
or bandage, and afterward moistened, the enlargement of the sponge producing 
an equable pressure. 

Case II. — Strangulated Inguinal Hernia — Operation; the patient being 
under the influence of Chloroform. — July 8th, 1848, at 11 A. M., was called 
to P. M. and found him lying on his side, with the knees drawn up, complain- 
ing of great distress in the abdomen. His story was, that some two hours 
before, while running fast in the field, in pursuit of a bull, he fell over a little 
hillock with great violence, and struck his abdomen, at the same time bruising 
his right testis; that he fainted and vomited, crawled on his hands and knees 
to the house, a distance of several rods, and dropped on the floor. 

There was great tenderness of the whole abdomen, especially in the right 
iliac and the hypochondriac regions. There was no complaint when the testis 
was handled, and there was no tumour in the scrotum. There was frequent 
vomiting, the surface of the body cold, and he was scarce able to whisper. 
Having apparently suffered severe concussion or other injury of the abdominal 
viscera, hot fomentations to the belly, heat to the extremities, and hot drinks, 
were ordered. By 6 P. M. there was considerable reaction, and the pulse 
about 90 and full, great distress in the abdomen on attempting to move, and 
great tenderness. Venesection was practiced, to approaching syncope, say ^x; 
gave calomel gr. x, and opium gr. ij. 

9th. 8 A. M. Felt better for the bleeding; tenderness and vomiting had 
continued. He now called my attention to a hernia in the right side of the 
scrotum, of the size of a hen's egg, which he had observed for the first time 
during the night. He stated, however, that he had had a hernia for fifteen 
years, which came down but occasionally, only after unusual exertion, and 
had always been easy of reduction ; and that it had not been down for several 
weeks before. Taxis was employed for over half an hour, and he was then 
bled to syncope; after which the bowel was easily returned on renewal of the 
taxis. The tumour was not tender, but there was exquisite sensitiveness about 
the internal ring. A firm, hard substance, of the size of the little finger, 
could be traced from the external ring, for an inch and a half, down into the 
scrotum, where it expanded and appeared to be in close contact with the testis, 
and was presumed to be a diseased spermatic cord. Pulse soft, and about 100. 
Ordered a purgative enema, having given a grain of opium. 

7 P. M. Bowels moved slightly after the enema; vomited after drinking. 
Felt better after the reduction, but the hernia had come down, of about half 
its former size. Tried taxis for fifteen minutes without success ; pulse very 
compressible; urgent thirst; great restlessness. Ordered cal. gr. ij, morph. 
\ gr. every three hours, to combat peritonitis, continued hot fomentations, ice 
ad libitum. 

9th. 10 A. M. Slept some; was free from the anxious distress of the pre- 
ceding day, and spoke louder; still vomited everything; tried taxis for a half 



1849.] Trask's Surgical Cases. 91 

hour; no tenderness of tumour; bled him to syncope; pulse 76, rather hard; 
before bleeding, was softer; taxis tried again, but no impression on the hernial 
tumour, which had resumed its original size, and was so tense as to be perfectly 
unyielding to pressure between the thumb and fingers, but not tender. Spoke 
to him of the operation. 4 P. M. Bilious vomiting ; tumour somewhat ten- 
der on pressure, which caused acute pain about the umbilicus. Ordered 
pounded ice to the tumour. 10 P. M. He had got up and walked into an- 
other room, and felt better. Ice applied for four hours, but produced great 
pain in the abdomen; pulse 76, soft and perfectly compressible; was so much 
under the influence of morphine as to be constantly disposed to sleep. 

1(M. 7 A. M. Had an uncomfortable night; ice was reapplied, but caused 
sharp pain in the bowels, relieved only by hot fomentations; had just had a 
spontaneous evacuation of the bowels,, and felt easier; pulse 76, not quite so 
soft. 12 M. Had had another evacuation, described as watery, with some 
blood; anxiety, tenderness, and distress increased. 3 P. M. Had had another 
dejection, and spoke up brighter, said he felt better; pulse 76, of natural 
force; tongue had a pretty thick covering of fur; vomiting at intervals, un- 
affected by opiates in any form. Calomel and opium had been continued, to 
combat the peritonitis which unquestionably existed, and the operation deferred 
from a great uncertainty felt as to whether there was actual strangulation, or 
mere peritonitis with inflammation of the neck of the sac. Was prevented 
from seeing him until 9 P. M. He had apparently begun to fail. The alvine 
discharges had not been preserved for inspection, as had been directed, and it 
was impossible to form an opinion whether they came from above the protruded 
gut or not. No diminution of tenderness or tenseness of the abdomen or of 
the tumour had followed their dejection, but on the whole he had failed more 
rapidly since they appeared. Pulse 100, and small; anxiety, distress, and 
tenderness, increased; preparations were now made for the operation. In an 
hour afterwards, pulse 110, and feeble, vomited green bilious matter; had had 
eructations for the preceding twenty-four hours, but no hiccup ; abdomen re- 
sonant as a drum. 

Drs. Palmer and Hodgson, of this village, kindly assisted me in the opera- 
tion. From the history of the case, no unusual increase of the thickness of 
the sac could be expected. The hardness of the tumour, however, was re- 
markable : it yielded not in the slightest degree to pressure, and felt like a 
scirrhous testis ; it was resonant on percussion. The patient, though anxious 
for the performance of the operation, was resolutely determined not to submit 
to it, unless allowed to inhale chloroform. From twenty to thirty minutes 
elapsed before he was insensible to the prick of a pin. An incision was made 
from over the internal ring to near the fundus of the tumour, through the 
integuments. After passing through what was considered to be the inter- 
columnar fascia, the loose straggling fibres of the cremaster muscle, and a layer 
of firm fascia, a thin membrane was exposed. This, when lifted up by the 
forceps, was snipped by the knife. About a drachm of clear serum escaped ; 
the sac was divided on a director up to the external ring, and afterwards 
above it. ' The finger could be passed in every direction excepting beyond the 
sides of the tumour, which lay in the sac, or rather behind it, after the 
manner of the testis in the tunica vaginalis. After deliberate examination, it 
was concluded that this was a false sac, and that we had yet to deal with an 
old and very thick sac enveloping the gut. No impression could be made on 
the tumour by pressure, and on following up the neck, which was an inch 
long and about the size of the little finger, it was found of the same hardness 
quite up into the inguinal canal. Selecting a spot at the left side of the 



92 Trask's Surgical Cases. [July 

tumour, where the external layer happened to be loose enough to pinch up, 
the dissection was continued. Layer after layer was divided until the knife 
caused a hollow sound, indicating that we were approaching the gut. 

Before this time the patient was repeatedly in a state approaching collapse ; 
and it had been necessary to pause often, to enable him to rally : at one time, 
indeed, he appeared in articulo mortis. No stricture could be felt at either 
ring, external to the sac. To undertake to lay open the neck was out of the 
question, from its great thickness and the density of its tissues. The dissec- 
tion was therefore continued, and we were evidently approaching the bowel, 
but the hemorrhage now became embarrassing; the walls of the incision had 
almost the firmness of cartilage, and presented a deep channel, constantly filled 
with blood, at the bottom of which, through dense, compact layers of con- 
densed cellular tissue, the dissection was to be carried on by candle light. 
The operation was continually interrupted by the sinking of the patient, 
accompanied by involuntary discharges of urine and feces, spasmodic twitch- 
ings of the muscles of the face, imperceptible respiration and frequent pulse, 
and the stomach rejecting everything that was poured into the mouth. His 
condition was so alarming as to cause apprehensions that he would die on 
the table, and, despairing of being able to distinguish the surface of the gut 
when it might be reached, a needle was passed into it for the purpose of 
relieving the distension. The point of the scalpel was afterwards introduced, 
and air, with a small quantity of dark offensive fluid, escaped. The wound 
was hastily closed, and the patient put upon the bed, to die, as was supposed, 
in a very little time. 

Saw him four hours after the operation, and he expressed himself relieved. 
Bowels had moved; tenderness of the abdomen much diminished; put him on 
calomel gr. ij ; morphine \ gr. every three hours. 

Next day 12th, 9 A. M. Tenderness of the abdomen gone; discharge from 
the wound very little but very offensive, and probably fecal ; was feeble. Or- 
dered brandy, one teaspoonful every hour, quinine gr. i, with morphine every 
two hours. 8 P. M. Has had several dejections; pulse 120, feeble and small; 
frequent vomiting. Ordered to give pil. opii gr. iss, every two hours : omit 
calomel and increase the brandy; sinapisms to abdomen. 

13th. Had profuse, constant, involuntary diarrhoea; pulse 120, and very 
small. Ordered brandy, ad libitum; laudanum and tannic starch injections, 
In the evening the discharge was checked. 

14th. 9 A. M. Passed a comfortable night; had been shaved, looked bright, 
and spoke up distinctly; pulse 108, soft, small, but regular; wound looked 
disposed to suppurate. Ordered one grain of quinine every three hours. 10 
P. M. Was bright until 4 P. M., then became faint, and was supposed to be 
dying; diarrhoea returned, but was kept in subjection by opiate enemata; vo- 
miting continued, resisting a blister to the epigastrium, doses of morphine, 
pills of opium and ice. He now began to complain of all stimulants as burn- 
ing his stomach. He became daily more and more feeble, the same symptoms 
continuing. No -pain or tenderness on pressure was experienced after twenty 
or twenty-four hours following the operation, until his death, which took place 
July 17th, at 10 A. M., seven days after the operation. 

Autopsy, 24 hours after death. Wound in a sloughy and exceedingly offen- 
sive state, and no attempt at union. On opening the peritoneal cavity, the 
peritoneum was found thickened, the intestines glued to each other and to the 
peritoneum all around the internal ring. These adhesions could be easily 
broken up, but they had prevented effusion of feces into the peritoneal cavity. 
There were several depots of pus between the convolutions of the intestines 



1849.] Trask's Surgical Cam. 93 

and the walls of the abdomen, one of which contained a teacupful. Viewed 
from the abdomen, the mouth of the sac presented a puckered appearance, 
like that of the neck of a purse tight drawn. The neck of the sac still felt 
like a hard cord, of the size of the little finger, and the passage through it 
barely admitted a middle-sized silver probe. On laying it open, a considerable 
quantity of firm lymph' was discovered, lining the neck and body of the sac, 
which had caused this partial obliteration of its calibre, and which could be 
readily stripped off. Its entire thickness was about a half inch. 

The gut, a portion of the ileum, had entirely retreated from the sac, into 
the peritoneal cavity, and had formed adhesions about the mouth of the sac. 
The opening which had been made during the operation, was half an inch 
in length, and the edges had become rounded off, without any attempt at 
adhesion. In a nearly circular space around the incision, involving from 
one-half to two-thirds the circumference of the intestine, it was of a dark 
purple colour, and its mucous membrane a little softened. (?) This appeared 
to be the portion that had descended ; so that the entire calibre of the bowel 
had not been involved in the hernial protrusion. 

This case presents several points of considerable interest. The protrusion 
at the time of the accident was evidently incomplete, and the intestine came 
down so as to fill the sac only after several hours, during which there was fre- 
quent vomiting. After its apparent reduction on the second day, it descended 
again within six hours ; partial relief to the symptoms followed, but it is now 
highly probable that the reduction was incomplete, a portion still remaining 
in the inguinal canal, though the frequent vomiting might have caused a re- 
protrusion, had it been entirely returned. It became a question whether 
strangulation had really existed, or whether the symptoms were due to in- 
flammation of the peritoneum and neck of the hernial sac. There had been 
from the first great distress and tenderness on pressure quite generally in 
the abdomen. He had expressed himself somewhat relieved by the apparent 
reduction, but not more so than after the previous venesection of the pre- 
ceding evening, and the vomiting and tenderness continued. I put him on a 
course calculated to combat peritonitis, and determined to wait a little before 
proceeding more actively. The operation was at length resorted to, after 
trial of all other means that promised any thing. There had been three pretty 
free alvine evacuations, but they had afforded no relief, on the contrary, he 
appeared to fail after the first. Their character was unknown, as they were 
not preserved as directed; one, passed just before the operation, certainly had 
the appearance of having come from the small intestines. The post-mortem 
examination showed that strangulation had actually existed, by the presence 
of the darkened spot above described, which, according to Mr. Teale, p. 62,* 
has been known to continue fifteen or twenty days after an operation. 

Whether the stricture was owing in this case to diminished calibre of the 
neck of the sac from effusion of lymph on its internal surface, subsequent to 
the protrusion of the intestine, or whether it depended on the great distension 

* Practical Treatise. 

No. XXXV.— July 7 1849. 7 



94 Trask's Surgical Cases. [July 

of the gut with air, I am not convinced. The tumour, it will be remembered, 
was pyriform in shape, with a long, narrow, undilatable neck, which, on post- 
mortem examination, was found lined with lymph, so that it would not allow 
the passage of more than a silver probe, and which, when freed from lymph, 
would not more than admit a small goose-quill ; and this lymph, or a portion, 
might have been effused after the descent of the intestine, and caused strangu- 
lation. On the other hand, " a sudden irruption of a fresh portion of intes- 
tine, or the generation of gas in the portion already protruded, may induce 
complete strangulation," says Mr. Teale, p. 54. On the puncture of the in- 
testine in the operation, air escaped, and the tumour became sensibly softened. 
Puncture of the intestine was our only resource, from the impossibility of 
pursuing the operation any farther, and the patient was thus afforded a chance 
for an artificial anus; moreover, in case the strangulation depended on disten- 
sion, it afforded a hope of relief. In those embarrassing cases in which, after 
removal of the stricture, the contents of the bowels cannot be returned by 
reason of great distension, " the over-filled intestine has been punctured with 
a large needle (Lowe), with a lancet (Loeffler), and with the trochar (Rich- 
erand, Jonas, Von Graefe); the latter was successful." {Glielius, Syst. of Surg., 
vol. ii. p. 39.) This practice, in the class of cases described, as well as when 
great protrusion of the intestines through wounds in the parietes of the abdo- 
men takes place, is one from which the best-informed surgeons now most 
generally dissent, but in our case delay was out of the question. 

Nothing could be elicited from the patient which threw any light upon the 
origin of the false sac found in front of the true sac. M. Cloquet has ex- 
plained the formation of similar protrusions of the peritoneum, of which the 
mode is described by Mr. Teale, p. 18, as follows : " When the entrance of 
the viscera into the sac is prevented, its neck has a remarkable tendency to 
contract, and, as it diminishes in size, it becomes more loosely attached to the 
hernial aperture. This contraction may proceed to such a degree as to pro- 
duce actual closure of the mouth of the sac. A serous bag then remains 
closed like the tunica vaginalis from the general cavity of the peritoneum. 
By the side of this closed cyst, a fresh portion of peritoneum may afterwards 
be protruded through the same hernial aperture, so as to form a new sac in 
close contiguity with the old one." In our case the neck of the false sac ran 
up into the inguinal canal, but owing to the great haste in which the examina- 
tion was necessarily conducted, no marks of obliteration of its mouth were 
looked for on the peritoneal surface. Its existence is the more remarkable, 
from the fact of his never having worn a truss. It must have been formed 
years before, since the true sac had evidently existed a long time. 

The thickness of the sac must be regarded as extraordinary. Though not 
ascertained by direct measurement, it was but little if any, less than half an 
inch. Though we are told that the sac is sometimes found much thickened, 
Teale and Lawrence each refer only to the case of Arnaud, in which the sac 
was six lines in thickness, and Velpeau to the additional one of Graefe, in 



1849.] Trask's Surgical Cases. 95 

which the sac was of similar thickness. It appears, however, that the various 
parts of the sac sometimes " undergo fibrous, fibro-cartilaginous, cartilaginous, 
or osseous changes of structure, either from inflammation, or from changes in 
the nutrition in the part consequent on pressure/ ' &c. This man repeatedly 
declared that the intestine did not ordinarily come down oftener than once in 
five or six weeks, and that it had never been down more than two or three 
days at a time. If this were true, the changes in the sac must have taken 
place independent of the presence of the intestine distending it. 

Lastly, I am inclined to attribute the very unusual depression under which 
the patient suffered during a part of the operation, and which imposed the 
necessity of hastening it to a termination, to the influence of the chloroform, 
which had been administered. From four to six drachms were made use of, 
while getting him under its influence, and during the time he was allowed to 
breathe it, after the operation commenced. The false sac was reached with 
facility, and having been opened, and the true state of things not being at 
once recognized, the inhalation of the chloroform was suspended. Almost 
immediately after the return of sensibility, the alarming prostration presented 
itself, and it continued alternating with intervals of reaction, during which 
alone any advance in the operation was made, the patient struggling vio- 
lently, until the completion of the operation in the manner narrated. The 
patient's condition when placed upon the table, was considered by us all, as 
very fair ; and the shock to the system from the operation, up to the time 
when the prostration first manifested itself, was entirely inadequate to the 
production of any such effects. It was with great difficulty that he had been 
brought under the influence of the chloroform — more than in any of the 
numerous instances in which I have witnessed its administration. 

Case III. — Suppuration beneath the palmar fascia — hemorrhage from 
incision — subsequent ligature of the brachial artery. Sept. 1847. — J. B., 
set. 9 years, applied at the Brooklyn Dispensary. Some four days pre- 
vious, on climbing a fence, a sharp iron nail entered the palm of his hand, 
and he hung by it until taken down by a passer by. Intense pain came 
on and had continued unabated. There were no positive indications that sup- 
puration had taken place, and nothing but the duration of severe inflammation 
to lead to the presumption of its having occurred. 

The boy was placed under the influence of ether, by causing him to inhale 
it from a phial by the nose, one nostril being closed by the finger, and the mouth 
shut. A free incision was cautiously made into the palm of the hand, in such 
a direction as to avoid the usual course of the superficial palmar arch. On di- 
viding the palmar fascia, about a teaspoonful of pus escaped, and pretty free 
hemorrhage came on. This was readily controlled by a compress over the radial 
and ulnar artery, confined moderately tight with a roller. He was put in bed 
with the arm on a pillow and the wrist placed higher than the elbow, and a 
bread and milk poultice applied to the palm. The relief was immediate and very 
great ; pain and swelling left the arm and hand, excepting the index finger, and 
the incision nearly healed by the first intention. Ten days after the incision 
was made, I was hastily summoned, and learned that, while dancing about the 
floor, he had accidentally struck a severe blow with his hand, and that he had 



96 Trask's Surgical Cases. [July 

lost two or three ounces of blood. Compression of the brachial artery with 
compress and roller controlled the hemorrhage, but obstructed the venous cir- 
culation. Compresses were firmly applied over the radial and ulnar ; ice was 
applied to the wound, but he would not tolerate direct compression upon it. 
In the morning there was a false aneurism, of the size of a bullet. A sixpence 
was enveloped in linen and applied directly over the sac, and over this a gra- 
duated compress retained by a bandage. Next morning, Oct. 1st, found he 
had passed a bad night, and he complained much of his hand. There was 
an offensive gangrenous smell, and on making moderate pressure and relaxing 
it, a large jet of arterial blood escaped. Compression in the palm gave him 
so much distress that he could not bear it. A compress was applied over the 
brachial artery, a thin strip of wood upon this, and a corresponding strip on 
the opposite side of the limb, and then a presse artere of a C shape embracing 
both. After repeated trials, it was found impossible to prevent the artery 
from slipping from under the pressure, any movement of the limb at once 
disturbing the instrument. The boy was of an exceedingly wayward dispo- 
sition and could not be controlled but by main force. A cylindrical compress 
was then placed in the course of the radial artery, and another in the course 
of the ulnar, and across the two the thin strip of wood above spoken of, with 
its long diameter across the wrist. A corresponding one was placed on the 
back of the wrist, and the two bound together by the presse artere. This 
controlled the hemorrhage completely. In about a half hour the wrist be- 
came very painful, in an hour and a half the pain was insupportable. When 
pressure was a little relaxed by means of the screw, hemorrhage returned. 
He had now lost a good deal of blood. 

Placing the boy in the lap of an assistant, I proceeded to put a ligature on 
the brachial artery. He begged permission to u snuff" the ether ; the phial 
was handed him, and in less than a minute he was completely under its influ- 
ence. He continued to inhale it, for four or five minutes, until the operation 
was completed. The first incision passing through the integuments and su- 
perficial fascia, some loose cellular tissue was divided by the scalpel, and the 
basilic vein came into view : this was drawn to the inside. On dividing the 
deep fascia, the medium nerve was drawn to the inner side. The sheath being 
exposed, a strip of the artery came into view, which was, in a large measure, 
hidden from view by the distended venae comites, lying parallel to it on either 
side. A bent-eyed probe was passed under the vessel, conveying a ligature 
which was tied. 

There was perfect union by first intention, excepting at the point where the 
ligature hung out. The ligature came away on the twentieth day, and in seven 
days more he was completely cured. 

The mode of inhalation practiced in this case is one which I described in 
the New York Annalist, soon after the introduction of etherization. It has for 
its recommendation, economy, and the most complete simplicity. Should it 
be desirable to bring the patient suddenly under the influence of chloroform 
or ether, it would probably be found in some cases that sufficient vapour would 
not be furnished in a given time. But this is not considered desirable by some 
who have had great experience. (See a Eeview of Dr. Channing's work in the 
January Number of this Journal.) Whenever there is no reason to anticipate 
any particular insusceptibility, I can confidently recommend its trial. A small 
phial should be half filled with ether or chloroform ; and held to one nostril, 



1849.] Blake on the Action of Poisons. 97 

the other being closed by a finger, and the mouth shut. Several deep inspira- 
tions should then be taken, as in snuffing heartily from a smelling-bottle. 

Case IV. — Case of Dislocation of the Metacarpal hone of the Thumb. — M. 
B., a tailor, accidentally fell down stairs, and in attempting to save himself, 
the weight of his body came (as he thinks) upon the extended thumb of his 
right hand. Considerable pain and swelling ensued, and the mobility of the 
thumb, though not lost, was much restrained. He presented himself two days 
after the accident. There was a projection under the skin, which could be 
easily pushed into its place, but immediately returned. It gave at first the 
idea of a dislocation of the trapezium, and had actually been taken for it by 
an intelligent friend, but its true nature was sufficiently apparent. In the 
course of five or six days, as many different kinds of splints and bandages 
were resorted to, to no purpose. A very small amount of force applied directly 
to the head of the bone sufficed to keep it in its place, but when sought to be 
effected through the aid of bandages and splints, unless applied so tight that 
he could not bear them, the head slipped out, the capsular ligament being 
torn. I had a clamp made of a piece of steel, a half an inch wide and one 
eighth thick and six inches long, bent into the shape of the letter U, with a 
screw passing through one end, perpendicularly to the surface. A compress 
was placed over the head of the bone, and one on the palmar aspect of the 
articulation, and a very moderate pressure from the instrument kept the bone 
in its place, and effected a perfect cure. 



Art. XI. — On the Action of Poisons. By James Blake, M. D., R B. C. S. E., 
Professor of Anatomy at the St Louis University. 

The subject of the action of poisons, has attracted the attention of physiolo- 
gists since this branch of science first began to be cultivated ; and undoubtedly 
the remarkable effects which many of the more venomous substances produce 
on the living organism, are well calculated to excite the attention, both of the 
philosophical inquirer and of the lover of the marvellous. It is not, however, 
until within the last few years, that any well-devised experiments have been 
performed with this class of substances, so as to make them available in illus- 
trating some of the phenomena of living beings. The researches of Fontana, 
Brodie, Orfila, Magendie, and Christison, have undoubtedly furnished us with 
many interesting facts on the action of poisons; and if, after all the labour 
that has been bestowed on it by these able experimenters, some of the more 
simple and fundamental problems connected with it have not yet received 
their solution, this dearth of useful results is not due so much to a want of 
care or accuracy, on the part of those who have instituted these researches, 
as to our ignorance respecting some of the fundamental problems of general 
physiology, — the solution of which would alone afford the necessary data for 
determining the most important questions relating to the action of poisons. 

One of the fundamental points connected with this subject, and one 



98 Blake on the Action of Poisons. [July 

which has attracted the greatest attention, is, as to the manner in which the 
more rapidly fatal poisons produce death : whether they must necessarily be 
absorbed and carried into the blood, before they can give rise to any general 
effects ; or these effects may be the result of an action they exert on the 
nerves of the part to which they are directly applied, and which may there- 
fore occur independently of their being absorbed? It is on this point that 
physiologists have differed; and most of the experiments that have been 
performed on the subject, during the last twenty-five years, have been insti- 
tuted principally with a view of determining this question. Yet simple as 
the nature of the problem might appear, and notwithstanding all the atten- 
tion that has been given to it, as yet, no decisive evidence has been brought 
to bear on the subject, or such, as in the opinion of most physiologists, is 
capable of definitely deciding the question. Some experiments which were 
performed a few years since, and were published in the Ed. Med. and Surg. 
Journ.j would I had hoped have been sufficiently conclusive to have decided 
the controversy. But as the conclusions which these experiments led me to 
have been called into question by Dr. Christison, in the last edition of his 
work on poisons, and also by Mr. Taylor, I propose to take a short review of 
the facts which have been published in my two former memoirs on this 
subject, and also to relate some recent experiments that have been performed, 
in the hope that the observations I have now to bring forward will be con- 
sidered sufficiently conclusive to decide this long disputed question. 

As to the great importance of our arriving at some definite and just conclu- 
sion on this point, there can be no doubt, when we consider how important, in 
the hands of the physiologist, is the class of substances whose action we are 
investigating. They are to him, in fact, what to the chemist are his reagents : 
the substances by means of which he introduces certain modifications in the 
living organism, in a manner analogous to that in which the chemist modifies 
the composition and properties of unorganized compounds by the various re- 
agents he employs. It would be well, whilst employing the term poison, to 
remember its close analogy with that of reagent ; the only difference being, that 
the latter term is applied more particularly to those compounds which are 
most used to determine changes or reactions in dead matter ; whilst the term 
poison, applies to those bodies which we employ to determine reactions in 
living beings. An investigation, therefore, of the action of poisons, involves 
one of the most interesting subjects of research to the scientific physiologist; 
nor should these researches be confined to animals alone : the great service 
that has been rendered to morphological physiology, by a comparative study 
of form in the whole series of living beings, will be afforded likewise to phy- 
siological chemistry, by as extended a series of observations, performed with 
our physiological reagents or poisons. 

The answer to the question, as to the manner in which poisons act, might, 
at first sight, be supposed to involve the whole of the phenomena connected 
with the changes they produce in living bodies ; but such is not the meaning 



1849.] Blake on the Action of Poisons. 99 

generally attached to it ; and we could not be furnished with a more striking 
proof of the rudimentary state of physiology, than is afforded by the restricted 
sense in which this question is used. Far from being able to enter into the 
investigation of the molecular reactions on which the effects of poisons 
depend, we are obliged to confine ourselves to the determination of the most 
simple and most mechanical problems connected with their action; and 
although volumes have been published on the subject, and whole hecatombs 
of animals have been sacrificed, yet physiologists are yet undecided as to 
whether a poison must necessarily be absorbed before it produces any general 
effects. This question is evidently one of the most simple, and at the same 
time the most fundamental, of any connected with the action of poisons : it 
does not involve a knowledge of the chemical properties of the solids or 
fluids of the body ; it does not even demand that we should be acquainted 
with the chemical composition of the poison we employ j we have not even to 
analyze the tissues on which we suspect the poison acts, for even its detection 
in these tissues would not throw any light on the subject. The research ap- 
pears, indeed, to be one surrounded with but little difficulty, and yet, how 
much labour has been spent on it, without arriving at any satisfactory result. 

It will be well, before proceeding farther, to endeavour to trace out the causes 
that have led to this want of success on apparently so simple a subject. There 
are, undoubtedly, many who will attribute it to the uncertainty which they 
suppose to be necessarily inherent to all experimental researches on animals; 
and who will thus endeavour to support that opinion which would deprive us, 
in elucidating the most complicated phenomena of matter, of that powerful 
lever of research, which has been so successfully used in almost every other 
branch of science. It may be well, indeed, for the speculator on physiological 
phenomena, to repudiate a method of research which involves a great deal of 
disagreeable labour, and the sacrifice of much time, but it must eventually be 
discovered that the most important advances in physiology will be attained by 
means of experimental investigation. If the experimental researches on the 
action of poisons have not led to any definite results, it is not owing to any 
fault inherent to the method itself, but on account of this method not having 
been followed out, in accordance with those rules by which every scientific 
inquiry should be conducted. 

In order to arrive at any satisfactory result in an experimental investigation 
on the absorption or non-absorption of poisons, there was but one physiological 
fact which required to be known previously to entering on such an investi- 
gation, as it involves data which are indispensable in determining the question ; 
this was, the time required for a poison to be conveyed by the blood from one 
part of the system to another ; yet, all the earlier experiments on the action 
of poisons, were undertaken without any correct data on this point, and, in 
fact, under the influence of most erroneous ideas on the subject; and it is 
not until within the last few years that the experiments of Hering and 



100 Blake on the Action of Poisons. [July 

myself, have afforded more correct data on the time occupied "by the blood in 
circulating through the system. 

It seems really surprising, that the manifest contradictions furnished by 
these experiments on poisons, did not lead to the suspicion that the data on 
which their action was explained must be wrong. For, on the one hand, it 
was found that poisons would give rise to symptoms of their action, and in fact 
destroy life, in a much shorter time than was believed necessary for them 
to be absorbed and carried by the blood over the system ; ergo, they must act 
by impressions conveyed through the nerves. But, on the other hand, it was 
ascertained that a poison applied to a large surface, abundantly supplied with 
nerves, did not produce any general effects as long as it was prevented from 
mixing with the blood ; ergo, they would not act by impressions conveyed 
through the nerves. Such an evident contradiction in the conclusions derived 
from these experiments, instead of leading to any doubt as to the correctness 
of the data on which they were founded, merely served to give rise to a new 
theory, which endeavoured to conciliate these opposing facts by introducing 
fresh errors into the investigation. I allude to the theory of Messrs. Addison 
and Morgan, which served to propitiate the believers in absorption, by finding 
that it was necessary that a poison should enter the blood-vessels before it could 
act, but that, when there, its farther effects were in accordance with the rules of 
sympathy, or owing to an impression conveyed through the nerves distributed 
on the inside of these vessels. This bastard theory on the action of poisons was 
that which, at the time I commenced my investigations on this subject, was 
most generally admitted ; but as it was soon proved that every fact brought 
forward in support of it was erroneous, opinion at present seems to be again 
falling back on the old explanation, viz., that some poisons act by an impres- 
sion they produce on the nerves of the part to which they are directly applied, 
whilst others produce their effects only when absorbed. 

The experiments I have performed on this subject, have furnished me 
with a mass of evidence which, without a single exception, leads to the con- 
clusion that the absorption of a poison must take place before it can give rise 
to any general effects. After having ascertained the correctness of the views 
of Hering in regard to the circulation, and having extended these researches, 
so as to ascertain the time required for the blood to circulate from one part of 
the system to another, in different species of animals, I was furnished with the 
necessary data for entering on the investigation of the action of poisons. 

My researches on the circulation had proved, that the time required for the 
blood to pass from the jugular vein, and to be circulated through the body was, 
in the horse sixteen seconds, in the dog twelve seconds, in the fowl six seconds, 
and in the rabbit four seconds; and it now only remained to be seen if a poi- 
son, introduced into the veins, would give rise to any symptoms of its action, 
in a shorter time than these facts showed was required for it to be circulated 
through the system. Should such be the case, then, it was evident that the 
effects of the poison must he the result of an action on the nervous centres, 



1849.] Blake on the Action of Poisons. 101 

propagated through some other channel than that of the circulation. If, on 
the other hand, it was found, that between the time of the introduction of the 
poison into the veins, and the appearance of the first symptoms of its action, 
a sufficient interval always elapsed for it to he diffused over the system through 
the medium of the blood, which interval would vary in different animals ac- 
cording to the greater or less rapidity of the circulation, we then have con- 
clusive evidence that it is by being absorbed and conveyed to the nervous 
centres that these poisons act.* A carefully conducted series of experiments, 
in which all the more rapidly fatal poisons were used, proved that in no in- 
stance did these substances show any symptoms of their action in a shorter 
space of time than that which would suffice for their general distribution 
through the system ; it was found that when large doses of the most rapidly 
fatal poisons were introduced into the veins, they did not, in the horse, give 
rise to any symptoms of their action in less than sixteen seconds, in the dog, 
in less than twelve seconds, in the fowl, in less than six and a half seconds, 
and in the rabbit, in less than four and a half seconds. 

These facts furnish us with a twofold proof as to the actions of poisons. In 
the first place, they show the improbability of their acting through the medium 
of impressions made on the nerves, by showing that they require a much longer 
time to act in some animals than in others ; whereas, we cannot suppose that a 
nervous impression is much longer in reaching the sensorium in a horse, than 
in a rabbit. They also show that at the moment that the action of the poison 
on the nervous centres first shows itself, it has already been conveyed to these 
organs by the blood, so that there is no occasion to invoke the doctrine of 
sympathy to explain its action. The deductions arrived at by these facts are 
much strengthened when it is shown by experiments, from which I endea- 
voured to exclude every source of fallacy, that poisons will not act when ap- 
plied to a part, the connections of which with the central parts of the nerv- 
ous system are unimpaired, provided they are prevented from entering the 
general circulation. For the details of these experiments, I must refer to the 
Edin. Med. and Surg. Journ., vol. liii. p. 55. 

I shall now proceed to offer some remarks on the criticism which both Dr. 
Christison and Mr. Taylor have made on my experiments, in the last edition 
of their treatises on poisons. In the first place, they state, that my aim in 
performing these experiments was to support a preconceived theory, rather 
than to elucidate the truth; secondly, that my observations are not entitled to 
so much confidence as are those of others who have preceded me; and, lastly, 
that the conclusions I have arrived at, are opposed to facts which they believe 
they have observed. I must, before proceeding any farther, apologize for the 
egotistical statements which these remarks will necessarily oblige me to make; 
but I do this with the less regret, as, by showing the falseness of the grounds 

* The poisons more directly alluded to, are those which evidently destroy life by their 
action on the nervous system. 



102 Blake on the Action of Poisons. [Jnly 

on which these gentlemen endeavour to invalidate my testimony, I shall add 
additional weight to the facts I have brought forward. 

I certainly must repudiate the imputation that is attempted to be cast on 
my experiments, by saying that they were undertaken to support a particular 
theory, for I believe I entered on these investigations with a mind much less 
likely to be prejudiced by erroneous views than those who had preceded me. 
I certainly had endeavoured, before proceeding to the investigation of the 
action of poisons, to satisfy my mind as to the truth of the data, a knowledge 
of which was necessary for its successful elucidation; and if, in so doing, I had 
arrived at new truths, which led me to conclude that many of the previous 
observations on this subject might be erroneous, I know not how this addi- 
tional knowledge could incapacitate me from conscientiously undertaking an 
investigation, in which these newly discovered facts should find their applica- 
tion. If, in support of the facts which I had brought forward to prove the 
rapidity of the circulation, it had been necessary to show that poisons could 
only act when absorbed into the blood, I certainly might have had my mind 
prejudiced in favour of such a theory; but the proofs of the rapidity of the 
circulation, in different species of animals, were arrived at by experiments 
which were perfectly independent of the question as to the action of poisons, 
and would not have been at all shaken had they been found to act by sympathy, 
or nervous impressions. If, early in my researches, I adopted the theory of 
the absorption of poisons, it was that this theory was found to harmonize with 
the facts that I had observed, and although some of these facts were opposed 
to the observations of others, yet, as these observations had evidently been 
made under the influence of erroneous impressions, I would not allow them 
to have that weight which the names of their authors might otherwise have 
demanded for them. It must be evident, I think, to every impartial observer, 
that Dr. Christison himself was far more likely to labour under preconceived 
views than myself, for placing, as he evidently does, the greatest reliance on 
the facts brought forward by Sir B. Brodie and others, as to the instantaneous 
action of poisons. I believe it to be impossible for so philosophical a mind as 
that of the author of the treatise on poisons, not to have been imbued with 
the idea that they must act by an impression conveyed through the nerves, as 
this is the only logical deduction which could be derived from such data, par- 
ticularly when we remember the views that were then prevalent as to the time 
required for the circulation of the blood. 

As to how far my observations are worthy of credit above those of others, 
this is a point which must eventually be decided by others besides Dr. Chris- 
tison and Mr. Taylor; but I would make one remark on an observation of 
Dr. Christison' s, concerning the accuracy of my statements in regard to the 
intervals of time at which the phenomena occurred. Dr. C states, " It is not 
unreasonable to claim for Sir B. Brodie, Dr. Freer, Mr. Macaulay, and Mr. 
Taylor, all of them practitioners of experience, the faculty of noting time as 
accurately as Dr. Blake himself." Now, without wishing to deny to any of 



1849.] Blake on the Action of Poisons. 103 

these gentlemen the faculty of noting small intervals of time, I would observe, 
that I consider myself to have possessed some advantages in this respect over 
those who had preceded me; for, before commencing my researches on the 
action of poisons, I had been occupied for some time in experiments in which 
it was essential that short intervals of time should be strictly noticed, and I had 
thus acquired some practice in observing physiological phenomena, under this 
point of view. At the commencement of my experiments on the action of 
substances introduced into the blood, I strongly experienced the difficulty that 
exists in accurately noting the periods at which physiological phenomena occur, 
particularly when they follow each other with rapidity. In fact, I have to regret 
that some of the experiments published in my first memoir on this subject 
contain errors, on account of my not having then acquired the habit of accu- 
rately noting time ; but, independently of the advantages which my previous 
experiments had given me in noting time, they had also shown me the import- 
ance of paying attention to short intervals of time in observing physiological 
phenomena — a fact which had never been so fully recognized by any who had 
preceded me, and who, therefore, were not likely to take those precautions 
which I adopted, in order to arrive at correct data on this point. But it is not 
on my own observations alone that the facts I have stated rest. Dr. Sharpey, 
who assisted Dr. Christison in his experiments, was also present when many 
of my experiments with conia and hydrocyanic acid were performed, and could 
bear testimony as to the accuracy of the facts recorded. 

As regards the objection raised against my observations, that they are all of 
a negative character, and therefore cannot invalidate the affirmative testimony 
of those "who had perfectly well observed what I had not been fortunate 
enough to witness," I would remark that this objection loses much of its force 
when we consider under what erroneous impressions these former observations 
had been made, and also that my conclusions do not depend on a single ex- 
periment, in which I might possibly not have witnessed what some more for- 
tunate experimenter had found; but that such should be the case in a long- 
series of experiments, varied in many ways, and more comprehensive than any 
of those which had been before performed, is a supposition too improbable to 
be entertained. 

Before proceeding to criticize the facts which have been brought forward 
as opposed to the conclusions I have arrived at, I regret to have to notice a 
mis-statement, which both Dr. Christison and Mr. Taylor have made, as regards 
my views on the action of poisons, and by means of which they have endea- 
voured to prove that the results I have arrived at must be false. Both these 
gentlemen state, when discussing the subject of the general action of poisons, 
that I have arrived at the conclusion that no poison will act on an animal in 
less than nine seconds; and then, having brought forward instances in which 
hydrocyanic acid had even produced death in a shorter time than I had stated 
was required for it to give rise to the first symptoms of its action, they, with- 
out the slightest difficulty, prove that my conclusions must be erroneous. Now, 



104 Blake on the Action of Poisons. [July 

in the memoirs before alluded to, I state that in the dog a period of nine seconds 
is required for a poison, that is introduced into a vein, to give rise to the first 
symptoms of its action. Nor can this statement be at all invalidated by Dr. 
Christison and Mr. Taylor, finding that hydrocyanic acid, when put into the 
mouth of a rabbit, will even kill the animal in less than nine seconds; for I 
have proved, and these gentlemen have copied the statement in other parts of 
their treatises, that, in the rabbit, the circulation is fully three times as rapid 
as in the dog, so that a poison may only require one third of the time to act 
in the former animal to what it requires in the dog; and I have also shown 
that a volatile poison like hydrocyanic acid will act more rapidly when applied 
to the tongue than when introduced directly into the veins, on account of its 
being inhaled into the lungs, and thus finding a shorter way to the brain, than 
when it has to pass through the right cavities of the heart. Had Dr. Chris- 
tison and Mr. Taylor fairly stated these facts, their observations, that hydro- 
cyanic acid would kill in less than nine seconds, would not have so cleverly 
overturned my conclusions. Had these gentlemen succeeded in proving that, 
in the rabbit, or in the cat, hydrocyanic acid, when applied to the mouth, will 
produce its effects in less than two seconds and a half, this fact would have 
been inconsistent with the views I had supported; but, notwithstanding their 
statements about the instantaneous action of this poison, I believe they have 
never seen it act in a shorter time than that above stated. 

I shall now proceed to notice the facts brought forward by these gentlemen, 
which they consider as supporting the theory of the sympathetic action of 
poisons. It would appear that the only experiments they have performed on 
this subject since the publication of my papers, have been made with concen- 
trated hydrocyanic acid, on cats and rabbits. It is unfortunate that, in 
endeavouring to test the correctness of a theory which is of considerable 
physiological importance, these gentlemen should not have better understood 
the nature of the problem to be solved; as then they would not have selected, 
for elucidating it, means which were precisely those least calculated to throw 
any light upon it, and in the use of which it was the most difficult to guard 
against sources of error. 

In selecting cats and rabbits to perform their experiments on, they could 
not have chosen worse ; for in these animals the rapidity of the circulation is 
such, that the difference in the interval which should elapse between the appli- 
cation of a poison and the appearance of the first symptoms of its action, 
would not, according to the one or the other theory, be more than two and a 
half or three seconds ; and I shall presently show that the determination of 
even this small interval is rendered doubly difficult by employing hydro- 
cyanic acid in these experiments. Had their experiments been performed on 
horses, or even on full grown dogs, the difference in the time in which a poi- 
son should act, according to the one or the other theory, would have been an 
interval much more easily observed. The extreme volatility of the concen- 
trated hydrocyanic acid renders it but little fitted for performing experiments 



1849.] Blake on the Action of Poisons. 105 

of this sort, particularly on the smaller animals, for it is necessary to use care 
that the acid should not be brought near the mouth of the animal until the 
moment that it is to be applied, otherwise the previous inhalation of the 
vapour would totally vitiate the experiment. Its volatility also enables it, 
when applied to the tongue, to find a shorter way to the brain than would be 
the case with a poison which could not be volatilized so as to pass directly 
into the lungs ; and this tends to render the interval that should be observed 
on the supposition of its absorption still shorter, and more difficult to be 
noted. 

Now, to the correct appreciation of tin's short interval of two and a half or 
three seconds, there appears to me to be an obstacle which renders it almost 
impossible for us to avail ourselves of these means for deciding which theory 
of the action of poisons is correct. This obstacle arises from the pain caused 
by the application of any quantity of the acid to the mucous membrane of the 
mouth. Owing to its extreme volatility, its sudden evaporation will cause 
great cold and pain, and I believe its vapour will, under these circumstances, 
produce irritation of the glottis; — from both these causes, struggles instantly 
follow the application of the poison, and it is almost impossible to distinguish 
these struggles from the first symptoms of its action on the nervous centres, 
which so rapidly follow. I have no doubt but these considerations will afford 
an explanation of the cases of instantaneous action, which both Dr. Christison 
and Mr. Taylor state that they have observed. 

The whole of the recent experiments with this substance, published by Dr. 
Christison, with the exception of one, tend to prove that the acid acts by 
absorption ; as they show that a sufficient interval elapsed, between the applica- 
tion of the poison and the appearance of the first symptoms of its action, for 
it to have reached the nervous centres. The only exceptional experiment 
was one in which the acid was used in sufficient quantity to produce pain and 
struggles at the moment of its application, and I have no doubt but that these 
struggles were regarded as the results of its poisonous action. On the pre- 
vious experiments, performed by Dr. Christison, with conia, I must still be 
permitted to doubt; as, in those which I made with this poison, I never 
observed it produce instantaneous effects. In these experiments also, Dr. 
Christison appears to have chosen those re-agents which were best fitted for 
leading him into error ; for they were performed on young animals, in which 
the rapidity of the circulation is so much greater than in those which are full 
grown. 

The evidence which Mr. Taylor brings forward in support of the sympa- 
thetic action of poisons, by quoting the statement of Addison and Morgan, 
that the Wourali poison would act even when it was not allowed to reach the 
brain, does not require any comment. But when the sources of fallacy 
which vitiated these experiments with the Wourali poison had been pointed 
out, he should not have brought them forward in a scientific treatise on 
poisons without, at least, stating the objections to which they were open. 



106 Blake on the Action of Poisons. [July 

I have performed some additional experiments on the action of these poi- 
sons since the publication of my former researches ; but as they are perfectly 
analogous to the facts that are already before the public, I think it better not 
to occupy your pages by entering into details. It will, however, perhaps be 
useful to relate one of them, in order to show the precautions that were taken 
to avoid error. The experiment was performed on a rabbit, concentrated 
hydrocyanic acid being used as the poison. One end of a small glass tube 
was blown out before the blowpipe, so as to contain about half a drachm ; 
this was filled with the poison, and the orifice of the tube closed with a glass 
stopper. The enlarged part of the tube containing the acid was introduced 
into the mouth of the rabbit, and placed, between the points of a strong pair of 
forceps, so that by closing the forceps, at a given signal, the tube would be 
crushed and the acid escape into the mouth. The advantages of this arrange- 
ment were, that it insured the application of the acid at the instant being 
noted with much greater certainty than could be obtained by simply pouring 
it on the tongue, and I also avoided all danger of the animal previously inhal- 
ing the vapour of the poison, as the tube was five inches long, and well closed. 
On the poison being applied the animal was left at liberty, so that we could 
more readily observe when it lost the power of voluntary motion. At the 
moment of the application of the poison, the animal seemed to suffer con- 
siderable pain ) it jumped off the table, and when on the floor of the room, it 
was perfectly able to stand on its feet. At two seconds and a half after the 
application of the poison it fell on its side, and it was dead in five seconds. 
This is but one of many experiments which have been performed on cats and 
rabbits, and in no instance have I observed instantaneous death, or even the 
instantaneous action of the poison. 

Were the theory of the sympathetic action of poisons to be judged but by 
these facts alone, it would not be difficult to disprove the statement of Dr. 
Christison, that " the balance of testimony is in favour of those whose accu- 
racy I impugn." But when we consider that this is but the weakest part of 
the testimony that can be brought forward, to prove that poisons can only 
act by absorption, when we take into service the facts furnished by so many 
experiments, which prove that the nerves are incapable of propagating the 
action of a poison from the part to which it is applied, and that it will not act 
unless it is allowed to enter the general circulation, we must admit that the 
theory of the sympathetic action of poisons, must either be supported by new 
and more conclusive evidence, or abandoned altogether. For these new facts 
I have as conscientiously sought as Dr. Christison and others \ and if I have 
not been so fortunate as to discover them, it is that I believe they do not 
exist ; and I think that, by using proper precautions to guard against error, 
they will escape the observation of others as well as myself. 

St. Louis, May 3, 1849. 



1849.] Dickson on Contagion. 107 



Art. XII. — On Contagion. By Samuel Henry Dickson, M. D., Prof: of 
Theory and Practice of Medicine in the University of the city of New 
York. 

The discussions upon this important and interesting topic have been of late 
assuming a more and more definite form, and we are now better prepared than 
at any former period for the consideration of the various doctrines which have 
been proposed and maintained in reference to it. 

There are two essential elements which go to the description of this source 
of disease; first, that it should be germinal, that is, self-multiplying, repro- 
ductive; and, second, that this reproduction should depend upon, or be fa- 
voured by the very processes of disease which itself gives rise to. 

The first of these propositions is undenied, and therefore need not be argued. 
A word has been coined to express this characteristic property of certain dis- 
eases by the Registrar-General of England, and is employed in his annual 
reports — " Zymotic;" the etymology of which, indicating an analogy with 
fermentation, might be imagined to intend a leaning to the opinion, that the 
organic germ of the affections thus classed is of vegetable character. But the 
phrase is loosely applied, including some endemics of which we cannot affirm 
the self-multiplication, and excluding many contagions, all indeed that are not 
febrile. The several modes of reproduction will be spoken of hereafter. 

In the present state of our knowledge of the history of contagion, we can- 
not venture to declare it to be the exclusive cause of contagious diseases. All 
such diseases must have had a commencement independently of such cause, 
the very existence of which is secondary and derivative in the nature of things. 
Nay, some contagious diseases begin now-a-days, under our own eyes, spon- 
taneously, or without perceptible connection with any source of contagious 
matter; as typhus, which none will doubt to be generated by filth and want 
of air, and low living ; and psora, which will always arise among any very 
uncleanly collection of people who are supplied with food and fresh air enough 
to retain their general health; and gonorrhoea, produced by a more local form 
of impurity ; and ophthalmia, developed by a certain concurrence of circum- 
stances in Egypt often, or constantly, and elsewhere occasionally; and plague, 
a denizen of the same region; and yellow fever, indigenous in some American 
cities, and upon the coast of Africa. 

The contingencies which give rise to typhus, psora, gonorrhoea, ophthalmia, 
pestis and yellow fever, may bring them into existence either directly or in- 
directly ; directly y by exciting the tissues of the body into the morbid actions 
in which these diseases consist ; indirectly, by first generating the matter of 
contagion. The former seems to me much the most probable. Life, whether a 
principle, property, or condition, is known to us only as derivative or secondary. 
u La vie ne nait que de la vie," the axiom of Cuvier, is absolutely true, Crosse's 
Electrical Acarus, and Weekes' Electrical Fungus to the contrary notwith- 



108 Dickson on Contagion. [July 

standing. It is not necessarily transmitted through an ovum, however, as 
Harvey laid down. Dead animal and vegetable matter assumes life by mere 
admixture, and interposition with living fluids and solids after digestion and 
absorption. Organisms of various form, cells and granules, receive life from 
other organisms in which life abounds, or from which it is transferred to them 
under an infinite diversity of contingencies of disease, and decomposition and 
decay. This transference of life we see hourly all around us; in the presence 
of morbid parasites, animal and vegetable; in the masses of animal and vege- 
table life produced during animal and vegetable decomposition ; and in the 
infinite abundance of infusoria wherever such decomposition can even be sus- 
pected. But the matter of contagion must be living matter, must be organ- 
ized, however obscurely or imperfectly; and in whatever character or form, 
whether simply cellular or of complicated structure, whether a fungous sporule 
or an animalcule, its capacity of self-multiplication, of indefinite reproduc- 
tion, necessarily implies its vitality. Nothing inorganic or inanimate can 
propagate itself. 

The facts that go to prove its germinal character are clear, abundant, and 
familiar to every one. If its presence were only one among several and varied 
circumstances, concurring in the production of a given disease, its absolute 
sufficiency, or exclusive efficiency, might be questioned; but we have nume- 
rous examples in which all the concurrent contingencies may be thoroughly 
changed, or entirely got rid of, as in inoculation with vaccine matter, small- 
pox, or gonorrhoea, or syphilitic pus; and yet the result be regular and uni- 
form. Hence, it is absolutely necessary to the definition of contagion, that 
each of its forms shall develop, or tend to develop, a materies morbi repro- 
ductive and self-multiplying ; and propagating itself through, and by means 
of, diseased processes similar to, and identical with, those from whence it 
sprung. 

The matter of contagion, as presented to us palpably, has undergone close 
examination and repeated experiment. In small-pox and vaccine, it exists in 
the limpid matter of the vesicle, lingers in the pus formed during maturation, 
and is still potential in the dried crust or scab. The foul fluids upon the sur- 
face of a chancre; within a syphilitic bubo, and the bubo of the plague; upon 
the conjunctiva in Egyptian ophthalmia, and in the gonorrhoeal urethra; in 
an itch pimple, and a herpetic vesicle ; all contain it, and admit of desiccation, 
without the loss of its characteristic and very peculiar properties. 

" All fixed contagions," says Berres, u are, at their origin, alike in form, 
consisting of larger or smaller globules ; we have no means of explaining the 
extreme variety of their effects and operations. We must allow a specific 
life and separate existence to contagion." Two assertions are made here, 
which should not be hastily received as established truths. I am not sure 
that the palpable matter of contagion has been actually seen in an insulated 
state, though the author just quoted describes it minutely. " Moist contagious 
matter," he says, (( is a vesicle § £$-$ of an inch in diameter with no trace of 



1849.] Dickson on Contagion. 109 

organization; the dry is in the shape of scales, scurf, or abrasions; its essence 
consists in an aggregation of semi-transparent, grayish-white globules T o,Wo 
of an inch in diameter." But if we reflect that the matter of contagion is, 
in certain cases, diffused in the blood, as well as mingled with the limpid fluid 
of a vesicle, and combined with pus, not to speak in anticipation of its im- 
palpable condition, we shall scarcely venture to conclude that we have detected 
or reached, and insulated it. The fluid of the vesicle contains it j it exists in 
the pus globule and in the cancer cell ; but the cancer cell, the pus globule, 
and the lymph of the vesicle, are composed of many elements, and do not 
consist of contagious matter only. Chemical analysis has shown nothing pe- 
culiar in either of them. Lassaigne's analysis of small-pox pus exhibits no- 
thing new or characteristic ; presenting only a larger proportion of saline in- 
gredients than is found in other pus. Like its composition, the form and 
appearance of contagious matter are unknown. Its minuteness is ultra mi- 
croscopic. ^ 

Nor can we admit without farther discussion, the assertion made so distinctly 
that it enjoys "a specific life and separate existence," in other words, a sort 
of parasitic condition. Vogel declares " the question, What are parasites ? is 
not yet ripe for decision." How are we to distinguish separate existence — 
true individuality ? Is there any test that we can apply with definiteness and 
certainty? 

Houston tells us tl that the microscope shows particles, floating in the blood 
of definite and uniform shape, endowed with a veritable organization, indi- 
vidually alive, and forming a living mass. The white globules are fruitful in 
the production of granules, which granules are themselves, each and all, pos- 
sessed of an independent life." 

Addison maintains "the existence of active molecules" (the granules of 
Houston) in the interior of the cells of blood, saliva, and pus, to have become 
an established physiological fact." But Williams expresses a reasonable 
doubt whether motion constitutes a proof of individual vitality as here inferred. 

The spermatozoa are treated of by Owen as members of the class entozoa, 
though he admits, " it is still undetermined whether they are to be regarded 
as independent organisms." These bodies not only present the phenomena of 
apparently spontaneous motion, like the blood globules above mentioned, and 
the moving filaments of the pollen of plants, and the inanimate particles 
enumerated by Williams; but they are reproductive probably. " There is 
reason," says Owen, "to suspect that they are oviparous; and they are also 
stated to propagate by spontaneous fission." 

What shall we say of the hydatid, so frequently ranked among parasites ? 
Owen, who recognizes it as "an independent organized being," denies it a place 
in the animal kingdom. But its chemical composition seems to forbid us to 
arrange it among vegetables ; and indeed Lallemand says that he has seen 
voluntary motion in the human acephalocyst. Its reproduction by gemmules 
is familiarly known. Tubercle, too, looked upon doubtfully as a parasite by 
No. XXXV.— July, 1849. 8 



110 Dickson on Contagion. [July 

Laennec, has been propagated, like hydatids, by Klencke, by inoculation. The 
cancer cell, which this author calls " semi-individual," both he and Langen- 
beck have propagated in that way. Is there then an intermediate condition, 
expressed as above, by the phrase " semi-individuality," in which we must 
place blood globules, spermatozoa, acephalocysts, tubercle, and cancer cells? 
For my own part, I regard the term as happily chosen, and, with the excep- 
tion of tubercle, which is a morbid product characterized by no vital property 
whatever, I would consider all the bodies mentioned as endowed with a de- 
rivative life, not an independent one, but capable of transfer and multiplica- 
tion. But the primary form of all life, which, according to Schwann and 
Schleiden, is cellular, is thus derivative and dependent. The lower we descend 
in the scale of vitality, the more transferable we find it. Thus vegetable 
gemmules live readily after inoculation or grafting; and thus some of the 
lower order of germs found in and upon the animal body, whether themselves 
animal or vegetable we know not yet, as the hydatid and cancer cell, and 
some fixed contagions. The property of reproduction belongs to all these ; 
but it has never been alleged to attach itself to tubercle. 

We have abundant proof that the matter of contagion exists diffused in the 
blood. Scarlatina and rubeola have been conveyed by inoculation with this fluid. 
Small-pox not unfrequently affects the foetus in utero; nay, there is a case on 
record, in which the child was attacked in the womb of a mother, exposed to 
the infection, but enjoying the immunity of a previous attack. It is a curious 
question, why this impregnation of the circulating fluid does not more gene- 
rally occur in pregnancy. It would seem closely analagous with the convey- 
ance of disease by transfusion in Coleman's experiments, and with the devel- 
opment of scrofula in the foetus, as in the instances given by Lloyd. 

A similar diffusion of contagious matter in secreted fluids, is presented in 
two examples at least. The hydrophobic saliva undergoes this poisonous change 
in the canine and feline tribes ; whether in the human subject, is not clearly 
ascertained. Thus also inoculation with the tears of a patient labouring 
under rubeola, is said to be efficient in communicating the disease. The same 
thing is affirmed to be true of the mucus from the nostril ; but this could 
hardly be procured free from some admixture from the tears trickling into it. 

In some of the fixed or palpable contagious matters, we find animalculse, 
which therefore, have been regarded as the cause of the disease, with which 
their presence is coincident; nay, as the very materies morbi. But we must 
not be hasty in drawing this conclusion. All diseases, or almost all, have been 
at one period or another ascribed to animalcular annoyance, and the question 
in regard to some of them still remains as doubtful as it is interesting. In 
some instances, the uniformity of the presence of animal life is denied. 
Dysentery was by Linnaeus ascribed to, an acarus, which few have been able 
to find. Klencke traces a connection between periodical attacks of vertigo 
and animalcule in the blood; but he stands alone in this opinion. Reese 
saw animalcule in recent black vomit ; but no one has since repeated the 



1849.] Dickson on Contagion. Ill 

observation. Beauperthuis and Boseville assert that they have uniformly found 
animalculse in cancer, to which they ascribe the disease, "erroneously/' says 
Vogel, " even allowing that infusoria do sometimes occur as incidental parasites 
in cancerous ulcers." Donne and Ehrenberg describe a parasitic animalcule, 
an acarus or a trichomonas vaginalis, as inhabiting the vaginal mucus in 
syphilis. But Grluge, Valentin, and Vogel, regard the minute objects thus 
denoted as mere debris of uterine epithelium. And even when the uniform 
presence of the animalcule is undoubted, it may still be the effect and not the 
cause of the disease with which it is thus coincident. " The parasite," says 
Vogel, "should never be identified with the disease itself." Yet Vogel un- 
hesitatingly ascribes psora to the itch insect. But psora is not only communi- 
cable by contact, but by fomites, upon which the exuding fluid has been long 
dry, as upon clothing, bedding, gloves, &c. It seems too much to assume, 
without proof, that the vitality of the minute acarus is retainable throughout 
an indefinite period of exsiccation, and that he may revive when moistened, 
ready for all the complicated functions of his peculiar mode of existence. 
Thus, also, certain vibriones being found in chancre pus, Donne regards them 
as the cause of lues venera j but Bicord denies this, upon the sufficient ground 
that bubo pus, containing no vrbriones, is also contagious. An experiment of 
pretty conclusive character, might, I think, be made in psora. As the insect 
is not always found in the fluid of the itch vesicle, it might be used for inoc- 
ulation, after careful examination with the microscope. The transfer of the 
insect taken from the fluid, would not be a test so satisfactory ; as his body 
could not be perfectly cleansed from the fluid in which he lives immersed. 

In certain contagious affections we discover the presence of parasitic vege- 
tation, and this with great uniformity ; as in tinea favosa, porrigo, and mentagra. 
The vegetable life here is always of the very lowest order, and is classed 
among the fungi. The same doubt exists here, as to the nature of the relation 
between the phenomena. Even by inoculation it is impossible to decide the 
question ; because, from the extreme minuteness of these productions, it is 
impossible to transplant the vegetable, without some of the diseased crust or 
dried fluid in which it has grown and fixed itself. 

We have now noted the several modes of alleged existence of the palpable 
matter of contagion. It is presented to us, 1. In the cell form. Langenbeck 
and Klencke have repeatedly conveyed cancer by inoculation with the cancer 
cell. 

2. In the newly produced fluids of the exanthemata: as in the lymph and 
pus of vaccine, variola, and varicella. 

3. In the pus globule of syphilis, of gonorrhoea, of Egyptian ophthalmia, 
and of plague bubo. 

4. In the ichorous exudation of herpes, of hospital gangrene, and it would 
seem of erysipelas also. 

5. In connection with the presence of animalculae, as, especially, in psora; 



112 Dickson on Contagion. [July 

less certainly in chancre pus, and, as Velpeau believes, in hospital gangrene, 
mentioned above. 

6. In connection with fungous vegetation, as in tinea and porrigo, mentagra, 
and plica polonica. 

7. In the blood, diffused as in scarlatina, measles, and small-pox. 

8. In some of the normal secretions, rendered contagious by this morbid 
admixture, as in measles and hydrophobia. 

I have already acknowledged that, although we thus apprehend and possess 
ourselves of the matter of contagion in these several modes, we have never 
yet separated or insulated it, so as to ascertain its external appearance and 
qualities, or detect its elementary composition or constitution in any instance. 
It has not been reached either by our best microscopes or our nicest chemical 
analysis. 

In addition to what I have already said of its specific life, its parasitic cha- 
racter, so boldly affirmed by some theorists, I remark, briefly, that of the known 
parasites, both animal and vegetable, it is not proved that they are, in any 
well settled instance, the causes of the diseased condition with which their 
presence is coincident. Some parasites are not morbid in any sense whatever. 
Look at the bark of a tree in a forest, or an orchard, and see how it is beset 
and mottled with lichens or mosses. The live oak of the south, the solemn 
druid of the woods, flourishes mantled in the flowing drapery of the tillandsia 
usneoides, the Spanish graybeard, as it is sometimes termed. Animals also 
are infested with dependent animal life, both within and without. Now, no 
one imagines that in their ordinary number the ectozoa are at all injurious to 
health. Wilson, after Simon, describes a cutaneous acarus, inhabiting the oil 
tubes of the skin, as not only harmless but useful, " by stimulating these tubes 
to get rid of any undue accumulation of their contents." 

Among the entozoa — which, as some naturalists maintain, are intruders 
from without, not natives of the regions they occupy, but immigrants from 
the external world — the most frequent and familiar to us, the intestinal worms, 
are only injurious to us incidentally, or, as it were, mechanically, by their un- 
due amount. Nay, Parr and Rush maintain that they are appendages of a 
sound constitution, and aid in preserving its healthy state, acting as scavengers, 
or in some other way. 

It is not by any means established that the fungi found on diseased surfaces 
cause the morbid condition with which they are associated. Yogel declares, 
that " they do not in general develop themselves upon mucous membranes, 
until, by morbid processes, a deposit of coagulated fibrine, which serves as a 
bed, has been prepared for them, and until this exudation has passed into a 
state of putrid decomposition." Yet it is not easy to perceive how this can 
be true of the fungi found in the aphthous affections of young children; nor 
can I imagine " a decomposing exudation within the sheath of the hair in 
mentagra," or in the interior of the hair roots in herpes tonsillaris and plica 
polonica. 



1849.] Dickson on Contagion. 113 

What, then, is the relation of parasitic life to contagion ? Shall we say 
with Vogel, that " the parasite should never be identified with the disease/' 
or coDclude with Prof. Mitchell, that " many diseases are proved to be dependent 
upon or arise from" parasites ? The first-named author has made a distinction 
between parasites and pseudo-parasites, entirely unsatisfactory and indeter- 
minate. The pathological interest of this branch of natural history lies in 
the assumed or discovered connection between the presence of animal or vege- 
table life and the symptoms attendant. Where no regular effect follows their 
presence, and it cannot be known or detected but by accident, our interest in 
the inquiry ceases. We cannot conjecture the existence of trichina spiralis, 
nor of the acephalocyst, nor the spiroptera, nor even of the strongylus — that 
is to say, there are no phenomena known to us as produced by them, or attend- 
ant specifically or otherwise on their presence. We do know pretty conclu- 
sively when a tenia resides in the digestive tube, though not, perhaps, with 
absolute certainty; so we may affirm also of the ascaris and lumbricus; the 
filaria is easily discovered; we infer the presence of the itch insect in psora 
readily enough, and of vibriones in chancre, and fungi in mentagra and porrigo, 
though we may not have seen them with our lenses. Perhaps it is not safe 
to say, in the present state of this department of science, that the former are 
accidental — do not belong to us — are merely temporary intruders when found ; 
but we surely find a natural and definite line of demarkation between such 
forms of animal and vegetable life as exist or are noted elsewhere and such as 
are peculiar to the human economy, and never are or have been seen anywhere 
else. These last are, in every sense, true — the former, ^se^cfo-parasites, in 
human pathology. Farther: if the absolute co-existence of certain specific 
morbid conditions, which never occur without and are never wanting to the 
presence of any definite form of parasitic life, be made out, and if these mor- 
bid conditions are communicable to healthy bodies by contact or near approach, 
it is illogical and unreasonable to refuse to consider the animalcule or fungus 
present as virtually the materies morbi. It finds in the diseased body its nidus, 
its soil, its local habitat; its transference to a healthy body is followed by the 
production of such disease as fosters it and propagates and multiplies it in- 
finitely. 

Whatever be the precise nature of a cell, whether animal or vegetable, 
whether absolutely an independent vitality, or a semi-individual, if it be never 
found but in the animal body, if always found in connection with and coinci- 
dent to some special form of disease, and if such disease be regularly produced 
when such a cell has been introduced into the organism, then it is a contagious 
cell; it contains the materies morbi. And so of animalculse and fungi; if 
found only in the animal body, if uniformly coincident with special diseases, 
which cannot or do not exist without their presence, and follow them when 
transferred, they convey the contagious principle — they are virtually the ma- 
teries morbi. It is Liebig's idea, that, in examples of successful inoculation, 
a sort of ferment takes place in the fluids; but fermentation is nothing but 



114 Dickson on Contagion. [July 

vegetable increase and germination. The analogy, however, is general. Each 
example is peculiar, separate, distinct. In every contagious morbid poison 
some new result has followed the combination of the elements which go to 
constitute it, which the highest magnifying powers of our best microscopes 
have not shown us, nor our nicest chemical analyses prevailed to detect, any 
more than they have made manifest the odorous particles of musk or of the 
rose. 

If this be true of the fixed and palpable contagions, what shall we say of 
the tenuity of those which are designated as impalpable, which offer to us 
nothing tangible, but confound us by their invisible potency, and evade us by 
their independence of all definite modes of limitation ? 

Variola, as everybody knows, is not only conveyed from a diseased to a 
healthy body, by the insertion into a wound of a portion of lymph or pus, or 
dried scab, from a pustule, but is efficiently active at a distance — a healthy 
body being infected in the neighbourhood of a diseased one. Now we must 
ascribe the phenomena here, either to the radiation and diffusion of the same 
materies morbi which is contained in the scab, pus, and lymph, and which, 
mingled with the blood of the mother, passes through the placental tissues and 
infects the foetus in utero, or we must assume the production and elimination 
of two efficient forms of contagious matter, the one fixed and the other vola- 
tile. But the first I have already proved to be ultra microscopic in the 
minuteness of the atoms which constitute it in certain cases, and, therefore, I 
see no difficulty in its elimination and radiation from the diseased body. It 
is, perhaps, relevant to observe, that this remote infection does not occur in 
any instance in which the parasite, whether animalcular or fungous, is visible, 
or has been detected by the microscope — it is chiefly confined to the febrile 
class of contagious diseases, and, perhaps, belongs exclusively to that class ', 
but as there is yet some dispute as to the febrile, or non-febrile, character of 
certain epidemics, I abstain from announcing the rule as established. The 
portion of atmosphere about the person of a small-pox patient becomes thus 
charged with contagious atoms. But, like all other zymotic diseases, small- 
pox, sporadic and perennial in great cities, becomes, from time to time, epi- 
demic — that is, widely and pestilentially prevalent. Healthy bodies are now 
infected in great numbers, most obscurely, and without known approach to a 
diseased body — the atmosphere is filled with the materies morbi. In the 
winter of 1847-48, 1 attended forty patients attacked with small-pox, not one 
of whom had ever seen a case, or consciously visited an infected neighbour- 
hood. Now we must conclude, either that the contagious matter is diffused 
in prodigious abundance from its human sources, or that some other source, 
atmospheric or telluric, exists, from which the disease or its cause may spring. 

But the spontaneous production of small-pox is contended for by no one. 
In this field of hypothesis, I do not hesitate to offer the suggestion, that in the 
animal exhalations collected in the dense population of a crowded city, the 
organic germs, fungous or animalcular — vegetable or animal, rather — may 



1849.] Dickson on Contagion. 115 

find occasionally all the elements essential to their germination and growth j 
and may multiply and propagate themselves in an atmosphere thus filled with 
animal matter adapted to their support and development. A bulb, or a seed, 
which ordinarily requires soil to vegetate in, will, nevertheless, grow if laid 
upon a surface which admits of the moistening of its roots, as we see every 
day in the flourishing of rice laid upon damp cotton, and the budding of a 
hyacinth in a glass bulb filled with water. Nay, the numerous air plants 
furnish us with a still closer analogy; and many of the lower classes of mi- 
nute insects will produce several generations in succession without access to 
their special food or habitat, as the aphis and the common tick of our southern 
country. Thus, then, whether we regard the materies morbi of contagious 
epidemics as fungous or animalcular, there is no difficulty in comprehending 
their propagation and extension, widely, actively, promptly, in dense popula- 
tions and crowded cities ; favored always, as we notice, by heat, moisture, and 
atmospheric stillness ; repressed, more or less, by cold, dryness, and ventila- 
tion, winds, or dilution of air. There is no more difficulty in explaining why 
a sporadic pestilence should be only occasionally epidemic, than in pointing 
out the causes which make one season prolific in familiar fruits and insects, 
and another as remarkable for their comparative scarcity. 

I have referred sj)ecially to small-pox ; but the same things are equally 
true of all the contagious diseases of which fever is an essential part, with the 
single exception of vaccine, which is incapable of affecting a sound body un- 
less admitted by a wound — and which gives out no radiation, no impalpable 
contagious matter. We must not forget, however, that it is not a human 
disease. Like glanders and hydrophobia, it is generated among the lower 
classes of animals, and, like them, it may be contagious by exhalation, or even 
epidemic, among its proper subjects. 

I have already mentioned the fact, that none of the non-febrile contagions 
are impalpable or diffusable in the air. All require contact. Even the itch 
insect does not travel; at least, he has never been met with on a journey. 

One great obstacle in the remaining steps of our inquiry, is the uncertainty 
how far we may allow ourselves to be led on by analogy. Variola shows us a 
palpable contagious matter, and also, undeniably, spreads abroad an impalpa- 
ble contagion; but no two contagious diseases present exactly similar pheno- 
mena. Scarlatina and rubeola have been communicated, we are told, by 
inoculation with blood, and the latter by means of tears. But we have now 
entered the domains of doubt and dispute, and as we shall find the mass of 
physicians denying the contagiousness of certain diseases, because no fixed 
mode of contagious matter has been detected in them, so, on the other hand, 
Chapman and Bell express their skepticism as to the existence of any palpable 
contagion in measles and scarlet fever, and prefer to attribute the infection of 
those inoculated by Home, Speranza, and Von Katona, to an epidemic diffu- 
sion of the impalpable materies morbi in the surrounding air. Following the 
general belief, however, as it is my own, I enumerate, as manifesting both 



116 Dickson on Contagion. [July 

the palpable and impalpable modes of contagious infection, pestis, erysipelas, 
hospital gangrene, and varicella, in addition to those above mentioned. I 
do not pretend to make the list complete, but wish merely to give varied 
examples. 

There are, besides these, certain diseases which have afforded room for 
almost interminable and angry discussion as to their contagious or non-conta- 
gious character. These exhibit no fixed or palpable materies morbi; all 
attempts to convey them from a diseased to a healthy body, by any mode of 
inoculation, has failed ; there is much irregularity in the proportion of infec- 
tions by near approach ; and yet they are regarded, properly, as contagions, 
because they are zymotic, rapidly and widely becoming epidemic, self-multi- 
plying, and easily propagated in dense populations and crowded cities — one 
case often serving as a focus around which is radiated a poison, intense and 
abundant enough to infect thousands with a morbid condition precisely identical. 
Such is typhus; such pertussis ; such puerperal fever ; such dysentery ; such 
yellow fever; such cholera asphyxia. Each of these has been the topic of 
vehement dispute ; but time, which affords the best touchstone of truth, has 
gradually accumulated facts enough to satisfy the more observing and philo- 
sophical authorities in our science ; and the period is at hand when all specific 
diseases capable of epidemic diffusion, that is, unconfined by any exclusive 
local limitation, shall be received into the same category, and pronounced 
contagious. 

Of these, I hold that they differ less than is generally supposed from the 
acknowledged contagious affections. It is true, that the materies morbi is not 
detained or fixed in any of the fluids of the body, or disposed to collect itself 
in any cell or globule ; nor does it assume any shape visible or tangible. But 
even in the so-called palpable contagions, I do not admit that we have detected 
the form, or outline, or composition of the contagious germ. With very few 
exceptions, already specified — with very few exceptions, and these, perhaps, 
admitting of some doubts — whether a cell or a sporule ; whether animal or 
vegetable ; whether mixed in blood, lymph, pus, tears, or saliva, it is ultra- 
microscopically minute and imperceptible. And in the febrile contagions we 
have examples of contagious matter unfixed, undetected, indescribably ten- 
uious, irregular, and entirely uncertain as to its limit and potency — as in 
variola, scarlatina, rubeola, and pestis. 

That the materies morbi in the disputed instances under consideration is, 
as in all other zymotic diseases properly so called, an organic germ capable of 
self-multiplication and reproduction, surely needs no proof. Otherwise we 
could not account for their extension and propagation, their absolute freedom 
from exclusiveness as to locality, their attendance upon migratory masses, 
their close adherence sporadically to well adapted foci, and their prompt mul- 
tiplication under fostering contingencies. These are not modes of existence, 
or laws of causative action of any known inorganic elements. 

That it finds a necessary nidus, centre, or habitat in the human body, is 



1849".] Dickson on Contagion. 117 

also evident from the fact that these diseases only prevail where there is 
crowded human life, whether in dense cities, or camps, or emigrant ships, or 
caravans; and that their virulence is always, ceteris paribus, directly propor- 
tioned to the density of population. 

There is no reason for our believing that contagion is exclusively animal or 
vegetable in its character. In different examples it may be of different nature. 
In either case the organic germs are liable to be repressed or fostered in their 
growth by contingencies known or unknown to us, the known having been 
already alluded to. In either case, they are capable of sudden multiplication 
to an unimaginable extent under favouring circumstances. I need not go 
into any statement of the possible increase of animalcular life, or the prodi- 
gious augmentation of masses of fungi — millions of each being generated in a 
few hours from a single individual, and the increase going on in an infinitely 
accelerated ratio. 

None of the hypotheses offered to enlighten and guide us in these our 
obscure inquiries are free from difficulties, it is true ; but the skeptics who 
deny the organic nature of the cause of these zymotic diseases, have chosen to 
contend with insurmountable obstacles. Let us select the example of Asiatic 
Cholera. It is so widely prevalent, that immense masses of the causative 
poison which excites it must exist on the earth's surface. This poison must 
either be generated wherever it is active, or it must have been produced origin- 
ally in infinite abundance to admit of its effective diffusion over such vast 
spaces. The first notion is most generally entertained ; but nothing can be 
imagined more contrary to all experience or analogy than the telluric elimina- 
tion, or the atmospheric production of the same inorganic, chemical, or me- 
chanical poisonous agent — call it malaria, or what you will — in the depth of a 
Russian winter at Moscow, in the burning summer heat of Hindostan, in the 
autumnal vicissitudes of weather at New Orleans, and in the changeable spring 
of the Rio Grande and the Ohio ) bidding defiance, alike, to climate, and sea- 
son, and temperature, and over-riding all local contingencies, all geographical 
and geological peculiarities j gushing from the alluvion of the Delta of the 
Ganges and the Mississippi, and the arid sands of the great Arabian Desert ; 
hovering over the granite of Staten Island, and the gneiss of New York, and 
the coal formations and calcareous soils of the Great West ; infesting alike the 
sea-coast and the shores of our fresh-water lakes, the banks of the Seine and 
the St. Lawrence, the Volga and the Thames — nay, exploding vehemently 
among the passengers of a solitary barque on the wide Atlantic, healthy until 
the moment of an abrupt fall of the atmospheric temperature. 

If the other horn of the dilemma be chosen, little appears to be gained. 
Wandering veins of cholera atmosphere, coming we know not whence, and 
tending we know not whither, cross the track of ships far away on the ocean, 
or touch upon the coast at remote points, as at Folly Island and the quarantine 
ground at the outlet of the Hudson and at New Orleans, rebounding to sea 
again, or disappearing into the upper regions of air, or following the angles 



118 Neill's Contributions to Pathological Anatomy. [July 

and windings of navigable rivers, and the inextricable mazes of roads and 
highways. 

It is curious, that some of those who admit and contend for the organic 
nature of the germs which constitute the materies morbi of certain forms of 
disease, should nevertheless broadly deny their contagious character. This is 
in each case a simple question as to the habitat of the germ, its favoring soil, 
its proper nidus, its source of life and nourishment. If these be in the human 
body — if, as Professor Mitchell expresses it, "the affinity is to the person rather 
than the place," surely the contagious character of the germ is decided. But 
it is not difficult to prove that, unless we except the immediate district around 
Jessore, there seems to be no special affinity to place, predicable of the cause 
of cholera. Its history shows it to be singularly migratory; and it is notable 
that no spontaneous infection with it has ever occurred in visiting any un- 
peopled region. Contrast it with malarious fever, remittent or intermittent, 
in this regard. Let a healthy man sleep in a remote rice field, a dismal jungle, 
or wild swamp, in a southern summer night; you may safely wager any odds 
that within three septenary periods he will be seized with disease of known 
type; but you can procure for such a one an attack of cholera no where but 
among subjects already labouring under the pestilence, or in their neighbour- 
hood, or as infected by fomites which have been exposed upon or near the 
persons of the sick. The cause of cholera, unlike the cause of periodical fever, 
may be transported with persons anywhere; in no place does it remain fixed; 
it is now totally extinct in many places where it once abounded. In all this 
it closely resembles the cause of small-pox, which surely relates to person and 
not to place; which finds its pabulum in a certain proportion of healthy bodies, 
and dies out when it has consumed it, or marches with them or their fomites 
to prey upon new food in other healthy bodies. 



Art. XIII. — Contributions to Pathological Anatomy . By Jno. Neill, M. D., 
Demonstrator of Anatomy in the University of Pennsylvania. [With five 
wood cuts.] 

Case. I. — An Oblique Fracture of both Condyles of the Femur united. — 
This specimen was presented to me by Dr. Benedict, from whom I obtained 
the following history of the case. 

An Irishman, of about 40 years of age, in attempting to escape from the third 
story of the Blockley Hospital, fell from a considerable height, and alighted 
upon his feet. Upon examining him immediately after the accident, the exact 
nature of the injury was not very evident. There was no crepitation, no twist- 
ing of the foot, no increased breadth of the knee, no difficulty in making 
passive flexion and extension of the leg. The deformity simulated that of 
a partial luxation of the tibia posteriorly; the leg was thrown backward and 
the patella very prominent. 

The case was treated by Drs. Benedict and Page for fracture, by a long 



1849.] 



Neill's Contributions to Pathological Anatomy. 



119 



Fig. 1. 



fracture box, and the usual antiphlogistic means, until the inflammatory 
symptoms had subsided ; and then passive motion was instituted to prevent 
anchylosis. In six weeks he was discharged perfectly able to walk, and there 
remained but little deformity and stiffness of the joint. A year afterwards 
he came into the hospital with typhus fever, of which he died. 

An accurate idea of the extent of the fracture can be obtained from the draw- 
ing. (Fig. 1.) It commenced about the middle 
of the trochleated notch of the femur and extended 
upwards for half an inch, and was joined by an 
oblique fracture upon each side, which completely 
severed the condyles. Yet they were not much 
separated, being held in situ by the ligaments, 
none of which were ruptured. There was, there- 
fore, no increase of breadth of the knee upon press- 
ing on the patella, a sign which Dessault considers 
as an especial diagnostic of this injury. The site 
of the fracture also accounts for the want of cre- 
pitation. Being in the cellular structure of the 
bone, the fragments were impacted by the great 
force and peculiar direction of the fall. Hence 
the shortening of the limb was so slight as almost 
to escape detection by measurement, or by the gait 
in walking. 

I find that this fracture is extremely rare, there 
being no case recorded by Sir Astley Cooper, Boyer, 
Hines, Chelius, Yelpeau, Smith, of Dublin, &c. 
But Dessault refers to a case reported in the Journal of Medicine, and records 
two cases which came under his own observation. The first occurred under 
very similar circumstances to the one just presented. The force was that of 
counter stroke; the man jumped from a window, alighted upon his feet, was 
killed and brought into a dissecting room. Preternatural mobility of the 
condyles was discovered, and upon dissection they were both found to be 
obliquely fractured and completely separated. The second resulted from 
kick by a horse. He treated it by his own apparatus for fracture of the thigh n 
and a cure was effected in sixty-four days. 

It is from his experience in these cases, that he states that " the signs are 
easily comprehended." 

" A very perceptible separation oftentimes exists between the two condyles 
increasing the transverse diameter of the knee. The rotula sinking into the 
chasm between the condyles, renders the part more flat from before backwards 
than it is in its natural state. If the rotula be pressed in a backward direc- 
tion, the condyles are separated still further from each other. If, on the other 
hand, pressure be made on each side of the os fern oris, the condyles are brought 
together and the knee resumes its usual shape. If we take hold of a con- 
dyle in each hand, it will be easy, by moving them alternately backward and 
forward, to make them rub against each other and produce a crepitation which 
characterizes the fracture beyond a doubt." None of these signs were present 
in this case. 




Case II. — Fracture of the posterior extremity of the Astragalus ununited. — 
Simple fractures of any part of the astragalus are considered as rare accidents. 
Force which is sufficient to fracture this bone, will very frequently render the 
injury compound or comminuted. 



120 



NeilFs Contributions to Pathological Anatomy. 



[July 



This specimen was obtained in the dissecting room, and no history of the 
accident can be learned. The subject was a young, black female, of about 20 
years of age. The right foot was smaller than the left, and much inverted. 
In fact, it was supposed to be a case of varus. But upon dissecting and pre- 
paring the foot, the true nature of the deformity was discovered. 

The fracture occurred in the line presented in the drawing. (Fig. 2.) The 

tibia was forced between the 
Fig. 2. fragments and greatly separated 

them. The larger fragment 
was pushed forward, and its 
anterior extremity turned in- 
ward ; in this position it was 
anchylosed with the os calcis. 
The smaller fragment was 
pushed backwards and re- 
mained movable. The tendon 
of the flexor longus pollicis 
pedis still played in its groove 
in this smaller fragment. The 
articular surface of the tibia 
rested upon the upper surface 
of the os calcis, where there 
was some attempt at the formation of a joint. From the changes which had 
taken place in the bony surfaces, the accident must have happened a long- 
time before I met with the case. 




Case III. — Renal Calculus in both Kidneys. — I was called to see a little 
girl, twelve years of age, early on Saturday morning, April 25th, who had 
suffered severe pain during the night. She was pallid, feeble, and thin, with- 
out fever; had a clean tongue, and natural skin, and complained of pain in 
the lumbar region, which was tender upon pressure. All of her secretions 
were natural, with the exception of the urine; it contained a heavy albuminous 
deposit. 

The mother reminded me of having treated the child for incontinence of 
urine, three years previously. The child was never cured; the incontinence 
continued, and occasionally she suffered pain. But her indisposition had never 
been sufficiently severe to induce the parents to apply for medical advice. In 
truth, she had been running about during the day preceding the attack of pain 
which was the occasion of my visit. 

Early on Sunday morning, the 26th inst., I was sent for again, in great 
haste. She had suffered another attack of pain, probably a fit of the gravel. 
When I saw her she was prostrate; skin cool and moist; pulse almost gone; 
lips livid; voice feeble ; countenance expressive of death. I directed stimulating 
drinks, and sinapisms. At one o'clock, she died. 

On Tuesday, the 28th, I made the post-mortem. There was no organic 
disease, except in connection with the kidneys. These organs were six inches 
in length, three inches in breadth, and two inches in thickness. The color was 
very dark, and the natural consistence destroyed. Upon opening them, I found 
the pelves, calices, and infundibula, greatly distended, and containing a large 
quantity of matter, partly albuminous, and partly puriform. The parietes 
were so thin, and the structure so altered, that none of the characteristic ap- 
pearances of the gland could be observed. The left ureter was much enlarged. 
The bladder presented no mark of disease. 



1849.] 



NeilFs Contributions to Pathological Anatomy. 



121 



It was impossible, under the circumstances of the examination, to dissect 
out these arborescent calculi, with all their stems, branches, and buds, without 
breaking them. But, after washing the fragments, the broken extremities 
were, for the most part, readily adjusted. 

They present the appearance represented in the accompanying drawings. 



Fig. 3. 



Fisr. 4. 





(Figs. 3 and 4.) The buds are perfectly white, and composed of a number 
of beautiful, shining crystals. Some of the stems are stained of a brownish 
tinge, others appear corroded, as if an acid had been applied. Their weight 
is 510 grains. Chemically, they consist of the phosphate of lime. 

In the Cyclop. Pract. Medicine, after the symptoms are described, the fol- 
lowing case is recorded : " A remarkable instance of such a calculus occurred 
in the person of a natural daughter of Sir Richard Steele. No nephritic 
symptom took place until shortly before her death, when severe pain was felt 
in the region of the right kidney; fever followed, and speedily proved fatal. 
A calculus of oxalate of lime, weighing seven and a half ounces, was found 
in the right kidney, which was so thin by absorption as to be reduced to a 
mere membrane. In this instance the stone could be felt, during life, through 
the loins, inducing the belief that the kidney had become ossified. — ( Catal. 
Museum R. Coll. Surg. London. Note by John Hunter.) 

Case IV. — Ossification of the Tendon of the Diaphragm. — This preparation 
was obtained from a subject in a dissecting room, and no history could be 
obtained of the case. 

The plate of bone was of an oval shape, an inch and a half long, and an 
inch and a quarter wide. It was situated at the summit of the cordiform ten- 
don, and presented the same characteristics as those bony lamellae which are 
frequently met with in the dura mater 



122 



Shipman's Case of Caesarian Operation. 



[July 



Case V. — Aneurism of the Vertebral Artery, within the Cranium. — This 
specimen was presented to me, some years since, by one of the house physicians 
at the almshouse. It was taken from a man who had suffered with some 
affection of the nervous system — I think epilepsy. 

It occurs in the right vertebral artery, half an inch from its junction with its 

Fig. 5. 




fellow, to form the basilar. Its shape is ovoidal, as is represented in the ac- 
companying drawing (Fig. 5.), which is of the natural size. 

The parietes of the sac were thickened by calcareous deposit in the middle 
coat of the artery. 



Art. XIV. — Case of Caesarian Operation. By A. B. Shipman, M. D., 
Professor of Surgery in Indiana Medical College. 

On the 10th day of June, 1848, I received an urgent summons to visit 
the wife of S. K., Esq., of East Solon, Courtland County, at about twenty 
miles from my residence. I did not arrive there until eight o'clock on the 
morning of the 11th, when I obtained the following history of the case. 
Mrs. K. was 41 years of age, had been married two years, up to which time 
she had enjoyed tolerably good health. Soon after marriage she began to 
enlarge about the abdomen, and the menstrual periods became irregular. 
She thought there was a tumour to be felt there. She consulted a physician, 
who thought it ovarian. After a while she said it burst and discharged, per 
anum, a large quantity of matter resembling pus and water, mucus, &c. The 
size of the abdomen diminished after this, but did not entirely subside. This 
tumour was on the right side of the pelvis. From this time until the present 
pregnancy, she enjoyed variable health, sometimes better and at other times 
declining; but a tumour was always to be felt in the abdomen. 

On the cessation of catamenia, at the commencement of the present preg- 
nancy, the abdomen enlarged rapidly ; so much so, that at the 4th month she 
was quite as large as women are ordinarily at the 8th month. There was 
severe pain, also, in the back and in the region of the tumour. When near 



1849.] Shipman's Case of Ceesarian Operation. 128 

the full period of utero gestation , she was so large that she thought, as did 
her friends, that she was pregnant with twins. Two t weeks ago she was 
taken with labour pains, and sent for her physician, Dr. Dayid McWhorter 7 
of Pitcher, Chenango County; he made an examination, but the os uteri 
was so high that he could not reach it. Dr. Lyman Eldridge and Dr. John 
McWhorter, of Cincinnatus, were also called in consultation, neither of whom 
could discover the os tincee by examination. After a while an anodyne was 
given, and the pains subsided, after existing severely for forty-eight hours. 
On the 8th, early in the morning, she was taken in labour. She called on 
Dr. David McWhorter. He made an early examination per vaginam, but 
could not reach the mouth of the womb. Some time after he was called, the 
membranes ruptured and a quantity of water came away. When the Dr. 
introduced his hand with great difficulty with a view of turning, and deliver- 
ing by the feet, he found the os uteri high up and to the left side, dilated 
sufficiently to admit the hand, which he carried up to the shoulder of the 
child, when it came in contact with a hard, resisting substance, which he sup- 
posed was another foetus, invested in its membranes. All his efforts would 
not enable him to pass his hand beyond this body, and after some time spent 
in fruitless attempts to accomplish delivery, he desisted, and sent for counsel. 
The two gentlemen who were formerly called, now were sent for, and each 
one made an attempt to turn the child, but with no better success. An attempt 
was then made to apply the forceps, but the head was so high, it being above 
the superior strait, that nothing could be accomplished in this way. It was 
then suggested that cephalotomy might be performed, but even this could not 
be done. All this time the pains kept up with great violence, until the even- 
ing of the 10th, when they subsided entirely, after they had continued nearly 
forty-eight hours without interruption. It was at this period that I was sum- 
moned. 

When I arrived, I found the three medical gentlemen in attendance, upon 
this forlorn case. The patient desponding; wishes to be left to herself; dreads 
an examination. Great exhaustion; pulse 120, weak; countenance anxious, 
haggard, and sunken. Examination per vaginam — parts tender, inflamed, 
swollen, and fetid gas escapes every few minutes from the vagina, with a noise 
showing that decomposition is going on fast within the uterus. I could not 
reach the child by the finger, and the parts were so exquisitely tender that I 
forbore introducing the hand. She refuses absolutely to have any farther 
attempts made to deliver her. 

From the known skill and tact of the gentlemen who had made the attempts 
at delivery, I was not disposed to make the trial myself; their opinions 
coincided that it would be impossible to deliver Mrs. K. by instruments, or 
the hand, by the vagina. What then was to be done ? Abandon the case to 
nature, who was incompetent to save her ; or trust to gastrotomy, with as little 
hope of success ? She had mentioned her wishes several times to have an 
operation performed ; but on talking the matter over among ourselves, we 
were unanimously of the opinion that it would be useless at this late hour. 
She was fast sinking ; signs of gangrene were already present, and life was 
fast ebbing away. When some one told her we were talking over the pro- 
priety of the operation, she became very anxious to have it done without 
delay. We stated to her the almost complete hopelessness of her case; that 
the operation would probably hasten the fatal catastrophe, by its shock upon 
the system. But to all these she interposed the certainty of a fatal termina- 
tion if left to herself, with no chance for life, but the unaided efforts of 
nature. In this dilemma, the question arose whether it was not our duty to 



124 Shopman's Case of Caesarian Operation. [July 

perform the operation of gastrotomy. We at once made the necessary prepa- 
rations, which occupied but a few minutes. A small dose of morphia was 
given her. She was placed in a recumbent position on the bed, and I com- 
menced the incision on the linea alba a little below the umbilicus, and carried 
it down to near the pubis. The first incision was through the skin, down to 
the facia; then through the facia and tendons of the muscles to the peritoneum, 
when a small opening was made into it, and enlarged to the extent of the 
original incision. The uterus appeared of a dark chocolate colour, lying far 
to the right side. An incision was now made into it, to the extent of perhaps 
eight inches; its walls were nearly half an inch in thickness, and parted under 
the knife as though partially disorganized. In fact the fibres parted in some 
measure before the knife divided them. The child was found with its occi- 
put towards the right sacro-iliac symphysis, but above the superior strait. It 
was entirely within the uterus, and a tumour, as large as the foetal head at full 
time, occupying the right side of the pelvis, and pushing the head on the left 
side of the pelvis, and completely preventing its descent into the cavity. This 
tumour was of a firm consistence, apparently of a fibrous character, and so 
situated as to partially fill the pelvic cavity, pushing the uterus to the opposite 
side, and, when the uterus contracted, forcing the head against the brim of the 
pelvis, where it was arrested. There was a portion of the uterus nearly cut 
through by the pressure of the foetal head against the sharp ridge at the brim 
of the pelvis. There was nothing but the peritoneal coat left, and that was 
very thin for several inches in extent. The child was of large size, and had 
been dead several hours. There was no difficulty in extracting it. The pla- 
centa was lying loose within the cavity of the uterus, but no hemorrhage of 
any amount had occurred. The whole being extracted, the uterus was care- 
fully sponged out, and the wound united with the interrupted sutures; adhe- 
sive plasters, and a broad bandage were applied. So Far the patient bore the 
operation with the greatest firmness; not a groan or a complaint was uttered 
during its performance ; on the contrary she expressed herself greatly relieved, 
remarking that she suffered but little, compared with her pains and distress 
previously borne. Her pulse was more calm and less frequent, immediately 
following the operation, than for a few hours preceding it. 

She continued in this state for a short time, perhaps an hour or more. 
We retired to another room, and were engaged in dining, when the nurse 
came to the door and informed us that the patient had fainted. We repaired 
to her, and found her perfectly dead. The nurse said that she saw no change 
until a minute or so before she died ; when she remarked that it grew dark 
in the room, and observed that she felt faint, and the nurse gave her a little 
camphor and water ; but it was the last she spoke, and immediately closed 
her eyes. The countenance became livid and pale, and she expired without 
a struggle. 

Remarks.— I have been induced to publish an account of this case, first, on 
account of the rarity of the cause requiring it, and secondly, from the con- 
viction that it is the duty of a surgeon to publish unsuccessful as freely and 
faithfully as he does the successful. This is a duty he owes the profession at 
large, and especially the younger members, who look to their senior brethren 
for examples. The faithful detail of cases of ruptured axillary artery, in 
reducing old dislocations of the shoulder joint, by Professor Gibson, of the 
University of Pennsylvania, has done more for the cause of surgery and 
humanity than a report of fifty successful cases would have done. We are 



1849.] Shipman's Case of Caesarian Operation. 125 

not to conclude that unfortunate cases have not happened, because they are 
not spread on the records of the medical literature of the day. That shrink- 
ing from responsibility, that fear of being censured by criticism, too often leads 
the surgeon to withhold his unfortunate cases from the public, and he more 
easily excuses himself from the task, as it is rarely he has a precedent to 
follow. 

It may be well to analyze this case a little, and inquire what was the cause 
of the impediment to delivery? and, likewise, what was the immediate cause 
of death ? In the first place, the tumour was so situated as to produce an 
obliquity of the uterus, pushing the foetal head out of the axis of labour, 
throwing the head of the child far to the left side, and forcing its head against 
the brim of the pelvis. The uterus did not descend into the pelvic cavity, but 
rested above the superior strait, with the head of the fostus pressing it against 
the bone to that degree as almost to part its fibres. Uterine inertia had 
taken place, and disorganization was nearly commencing. What was the im- 
mediate cause of death ? We did not examine the patient after death j the 
friends were unwilling that it should be done. 

It is possible that hemorrhage may have occurred, but there were no external 
signs of it, none by the vagina, and there was no distension of the abdomen 
to be discovered; still, as the uterus did not contract after the contents 
were removed, we might have inferred that hemorrhage would be likely to 
ensue. But there was no tendency to hemorrhage when the operation was 
performed. The placenta was detached, and had been for some hours, and 
yet no bleeding was present. When the uterine fibres were divided, no blood 
made its appearance, nor at any time while the wound in the abdomen was 
exposed. There was no effusion into the cavity of the abdomen. The liquor 
amnii was drained off long before the operation. The intestines were not 
troublesome during the operation; indeed, I did not see a single coil of intes- 
tine, as the assistants kept the walls of the abdomen closely applied to the 
uterus before and after the incisions were made; this they were directed to 
do, not only for the purpose of preventing blood from falling into the 
cavity of the abdomen, if there should be much lost, but also to prevent the 
intestines from being exposed to the air. My own opinion is that the powers 
of life in this patient were nearly exhausted, and that it only wanted this 
additional shock of the operation to carry her off at once. A few hours 
would have caused her to sink, without the operation. 

Had she survived the operation, the tumour, in all probability, would have 
destroyed her. It was large, and extensive adhesions united it to the sur- 
rounding tissues, so that its removal would have been a serious proceeding. 



No. XXXV.— July, 1849. 



126 Yardley, Complete Inversion and Expulsion of the Uterus. [July 



Art. XV. — Complete Inversion and Expulsion of the Uterus. By Thomas 
H. Yardley, M. D., Consulting Physician to the Lying-in Department of 
the Northern Dispensary of Philadelphia, &c. 

At five o'clock P. M., Jan. 5th, 1 found on my slate a message, requesting 

my immediate attendance on Mrs. H , a lady whom I had engaged to 

attend in her accouchement. I hastened to her residence, where I learned she 
was alarmingly ill ; that she had been delivered of the child for at least two 
hours; that the afterbirth had not yet come away, and that she had fainted 
repeatedly. 

I found her lying across the foot of the bed, entirely pulseless, skin cold 
and clammy, and her voice nearly inaudible. Her attendants were in great 
consternation, and one of them sat at the foot of the bed, holding on to the 
cord, for the purpose, as she said, of preventing it from " going up." I di- 
rected some brandy and water to be given her immediately, and on passing 
my finger along the cord, I came in contact with a large solid body, which I 
at first thought was another foetus protruding from the vagina ; but a very 
slight examination satisfied me it was the placenta, attached to the inverted 
uterus, which had passed entirely out of the vulva. 

I immediately separated the placenta, which was very slightly adherent, 
and then placing my fingers in a conical position, I pressed them against the 
middle of the inverted uterus, and returned it to its proper position with fa- 
cility. Another difficulty now presented itself: the uterus did not manifest 
the slightest disposition to contract, and was so flaccid that I felt satisfied it 
would not retain its position if I withdrew my hand; I therefore kept it in 
the cavity of the uterus, and gently irritated its internal surface. The hemor- 
rhage was very slight ; but the patient was already pulseless, and the attend- 
ants so much alarmed as to afford very little assistance. 

I directed stimulating frictions to be made to the extremities, and sent 
one messenger for my friend Dr. Janney, and another for some vinous tinc- 
ture of ergot, which I gave in doses of a teaspoonful every ten minutes, with 
a tablespoonful of brandy and water. 

I retained my hand in the uterus half an hour before I felt the slightest 
contractions; they then came on, at short intervals, with increasing strength; 
and, after Dr. Janney arrived, we considered it safe to withdraw my hand. 
Dr. Janney placed his hand on the abdomen, and satisfied himself that the 
uterus continued to contract ; the patient, however, continued so ill, that he 
gave me his valuable assistance for two hours, during which time we plied her 
freely with brandy, camphor, carbonate of ammonia, and other stimulants, 
and applied cloths wrung out of hot capsicum and turpentine to her extremi- 
ties. Under this treatment, she gradually rallied ; but it was not till after mid- 
night that I considered her sufficiently revived to leave her. 

Her convalescence was tedious, but perfect; and the child did well, though 
there was not the slightest secretion of milk. 

I am aware that many authors of merit recommend that the uterus should 
be reverted before the placenta is detached ; and this is no doubt proper prac- 
tice where the uterus is within the vagina. But where an unusually large pla- 
centa, as in this case, has passed entirely out of the os externum, I think it would 
be a difficult task to force it back again, and further, as I doubt the propriety of 
making the attempt, particularly as I am not aware of any evil having resulted 
from first separating the placenta; and in many cases in which it has been at- 



1849.] Ramsay's Gases of Spontaneous Luxation of the Hip Joint. 127 

tempted to replace the uterus with the adherent placenta, it was found impos- 
sible to succeed. Professor Meigs, in his recent work on obstetrics, records a 
case in which both he and the late Professor James tried without effect — 
and I am sure that no one acquainted with these gentlemen could doubt their 
skill and perseverance ; — but they were compelled to detach the placenta before 
they could replace the uterus. 

What influence traction of the cord had in this case, I am unable to deter- 
mine. The patient was an exceedingly delicate woman ; this was her second 
accouchement, and she had recently undergone much bodily fatigue, and mental 
anxiety and depression, in consequence of the illness of her husband, who 
had died a few weeks previously of phthisis. She had taken a dose of oil in 
the morning, which operated freely, and so rapid was her labour, that she 
had barely time to get on the bed before the child was born. 



Art. XVI. — ■ Two Cases of Spontaneous Luxation of the Hip Joint. By Henry 
A. Ramsay, M. D., Raysville, Ga. 

I am aware that luxation of the hip joint spontaneously is not without 
precedent ; but the following cases offer some points of departure from the 
general course of such accidents, which have induced me to present them in 
a succinct form before the profession. Both of the following cases occurred 
in the same family, and were of peculiar interest to me, notwithstanding they 
produced painful impressions, owing to their intractability and utter hope- 
lessness of relief. 

The first case was in a small lad, six years of age; his temperament was 
phlegmatic, his muscles soft and flabby ; his health was not greatly impaired 
until within a few weeks previous to his demise. His father died with con- 
sumption; his mother is a hale, hearty woman, and not predisposed to any 
scrofulous disease. When he was about four years of age, his parotids were 
tumefied, as I was informed; he was supposed to be scrofulous by the physi- 
cian who then attended him ; I learn that he had some ulcerations of that 
character; he, however, recovered from these, and seemed to be in very good 
health up to the month of January, 1847. About this period, without com- 
plaining of any pain, or without any symptoms of previous swelling or ulcera- 
tion about the joint, he began to limp. I was called in a few weeks subse- 
quent. I found him running to and fro about the house, quite lively, cheerful, 
and playful; he was limping very considerably, but had no expression of 
pain, nor did his countenance exhibit any. Upon a minute examination of 
the joint, I found no tenderness upon pressure, and but little upon rotation; 
there was no swelling of the inguinal glands, nor was there any wasting of 
the nates. The limb was very considerably shorter than the other; the toes 
rested upon the instep of the opposite foot; the heel was elevated, the knee 
turned inwards, and the head of the bone could be distinctly felt upon the 
dorsum of the ilium. The patient continued in this situation for several 
months, running about the yard, playing with the other children, until a few 
weeks prior to his decease. During the time, his grandfather, on account of 



128 Ramsay's Cases of Spontaneous Luxation of the Hip Joint. [July 

his entire freedom from pain, or restraint in getting about, became very soli- 
citous for its reduction. But, as I was sure it was dependent upon some scro- 
fulous disposition, I gave my decided opinion against it. The old gentleman, 
however, desired me to consult Professor Ford relative to it. I did so, and 
he concurred; several other physicians were consulted, and all with the same 
success. 

The little patient continued to associate with his playfellows as usual, until 
the fall of 1847, when he was attacked with intermittent fever; his knee 
began to pain him, particularly at night; his limb began to waste; his gene- 
ral system deteriorated ; he lingered for a few weeks in intense agony, from 
which no remedy seemed to relieve him, until death interposed its power. 

The second case was a little negress, now living, aged five years, who was 
attacked last spring with measles. Some eight weeks after her convalescence, 
she was observed to limp in walking, and that, too, without any premonition, 
as the family informed me. I was called. An examination of the limb deve- 
loped a complete dislocation of the femur, upwards and backwards, upon the 
dorsum of the ilium. This patient continued to play about for several weeks ; 
at length she complained of pain in the knee at night, gradually grew worse. 
until she was confined to the house. Recently, some swelling has appeared 
about the joint, and tended speedily to ulceration ; under a course of treatment, 
however, the swelling subsided, and when I last saw the patient, a few weeks 
since, she was walking with the assistance of a stick. 

No other ulcerations of a scrofulous character have presented themselves at 
any time upon this patient since having measles. 

These cases seem to me to present the following unusual points : — 

1st. The absence of pain in both cases, prior to, and subsequent to, the luxa- 
tion. 

2d. The apparent absence of an ulceration of the cartilages, which usually 
precede, or furnish a cause for, such dislocations. 

3d. The ability of the patients to sport and play during the existence of 
the luxation, with an entire immunity from pain till within a short period of 
death or confinement ! 

In conclusion, what caused the dislocations ? I am inclined to think that 
all the circumstances justify the conclusion that it was a deposition of callus 
in the acetabulum. This is merely an opinion, founded upon analogous cir- 
cumstances ; and as such, I throw it out for what it is worth. 

Lincoln County,, Ga., April 18th, 1849. 



1849.] 129 



REVIEWS. 



Art. XYII. — Practical Treatise on Ventilation. By Morril Wyman. 12mo. 
pp. 404. Boston : Jas. Munroe & Co., 1846. 

Report of a Committee of the American Academy of Arts and Sciences on 
Ventilation and Chimney-tops. 8vo. pp. 28. Cambridge: Metcalf & Co., 
1848. 

Practical Methods of Ventilating Buildings. By Luther V. Bell, M.D., 
LL. D., Honorary Member of the New York State Medical Society, etc., 
Physician and Superintendent of the McLean Asylum for the Insane — a 
department of the Massachusetts General Hospital. 8vo. pp. 131. Bos- 
ton: Damrell & Moore, 1848. 

Ventilation of School-Houses of the City of Boston. Report of Committee. 
8vo. pp. 43. Boston: J. H. Eastburn, 1848. 

Ventilation Illustrated: a Tract for the Schools of Rich and Poor. 12mo. 
pp. 36; second edition. London : John Churchill, 1848. 

Uses and Abuses of Air : showing its Influence in Sustaining Life and Pro- 
ducing Disease ; with Remarks on the Ventilation of Houses. Parts I. and 
II. ; 12mo. pp. 144. New York : J. S. Redfield, 1848. 

This long list of works on the subject of ventilation, most of them pub- 
lished within the last year, and all of them within two years, shows a very 
great increase of interest in, and of attention to, this subject. They are 
indications of the interest which some scientific and charitable societies, 
and some public authorities, have felt in this matter, and of the efforts which 
they have made to call the attention of the people to it; for they all emanate 
from, or come to, the world through some such public authority. 

The Boylston Medical Committee, of Harvard University, proposed the sub- 
ject of ventilation of hospitals, churches, public halls, dwelling-houses, shops, 
&c, as one of the subjects for a prize dissertation. Dr. Wyman was the suc- 
cessful competitor; and the work now before us is his dissertation, enlarged and 
adapted to public use. 

In 1847, Br. Bell was appointed to deliver the address before the Massa- 
chusetts Medical Society, at their next annual meeting. He selected ventila- 
tion of buildings for his subject; and in May last delivered the address which 
we now have in the volume before us, published by the Society in their trans- 
actions. 

In 1847, the Boston School Committee appointed a sub-committee to inquire 
into the possibility and means of ventilating the city school-houses. Henry 
G. Clark, M. B., was at the head of this committee, and to him are we in- 
debted for the valuable tract before us. 

The American Academy of Arts and Sciences appointed a committee to 
inquire into the practical value of the various kinds of ventilators and chim- 
ney-tops. Dr. Wyman, one of this committee, subjected these various instru- 
ments to the test of experiment, and made the above report, which is published 
among the Society's transactions. 

An association of gentlemen in New York proposed to publish a series of 



130 Reviews. [July 

works called "Tracts for the People," in which they intend "to discuss the 
application of Christianity to the institutions, classes, and social economy of 
large communities." These tracts, Nos. I. and II., are Parts I. and II. of the 
Treatise on the Uses and Abuses of Air. No author's name is affixed to this 
work ) but we may venture to impute its paternity to a writer of authority in 
matters of hygiene. 

" The Samaritan Fund Committee of the St. G-eorge's and St. James's 
Dispensary," London, in order to encourage the introduction of ventilation 
into the houses of the working classes, issued their tract, as above described ; 
"and, by thus diffusing information on this important subject of ventilation, 
they hope to create a want for it among all classes of the community, and es- 
pecially among the poor, who suffer so much disease from continually breath- 
ing the impure air of close and confined apartments." No author's name is 
given, nor have we any means of knowing the names of the Samaritan Fund 
Committee, who are responsible for its authority, except that Joseph Toynbee, 
F. R. S., the eminent and philanthropic surgeon, is the honorary secretary, 
whose name is sufficient guarantee that it came from proper authority. 

Besides these works, we frequently meet with articles in newspapers and 
magazines upon ventilation. The works of general hygiene and of popular 
physiology treat of this subject among others connected with their general 
purpose. Lyceum lecturers, and those itinerant instructors of the people who 
show the human structure, and explain the laws of bodily action and of health, 
include this in the course of their public teachings. 

All these show that this subject, the use of air in the animal economy, and 
the necessity of frequent supplies of this element, is becoming one of gene- 
ral interest, and that it has now entered, at least, upon the high road to popu- 
lar appreciation and acceptance. 

All the works which we have enumerated in the beginning of our article 
are good in their way, and though, with the exception of the first, Dr. Wy- 
man's book, none pretend to be perfect treatises upon ventilation, yet each 
one has a single and definite purpose to fulfil, which it has faithfully accom- 
plished. Each of these works may therefore be considered as valuable ad- 
ditions to popular science, or useful channels through which science, in some 
of its principles or applications, has been carried, or is now going, to the people. 

Dr. Wyman's work is a full treatise upon the whole subject of ventilation 
in all its varieties and means, and also touches indirectly upon the subject of 
warming. But the full consideration of this last topic, for want of room in 
the present work, is postponed — we trust, to be resumed, and the result given 
to the world, at Dr. Wyman's future leisure. Dr. Wyman's plan is best 
described in his own words : — 

"First, to describe the laws and properties of gases generally; especially 
the laws of their diffusion, so important in its influence upon ventilation. 

" Secondly, the chemical and physical properties of the atmosphere. 

" Thirdly, the processes by which atmospheric air may become vitiated ; 
particularly the processes of respiration and combustion, and the nature of 
the gases produced by them. 

" Fourthly, the means by which impurities, whether chemical or mechani- 
cal, may be removed from atmospheric air. 

" Fifthly, the principles of the movements induced in air by heat, especially 
those occurring in apartments and in chimneys. 

" Sixthly, the moving power best adapted to ventilation, and the quantity 
and qualities of the air which should be supplied. 



1849.] Treatises on Ventilation. 131 

" Lastly, the mechanical arrangements best adapted to effect the ventilation 
of the various structures to which they are applied." 

Dr. Wyman begins with the first principles, and describes the air, its com- 
position, and its chemical connection with animal and vegetable life, and shows 
the reciprocal services performed by plants and animals — in the supply of oxy- 
gen by the former for animal respiration, and the supply of carbonic acid by 
the latter for the support of vegetables. 

Dr. Wyman, quoting Mr. Dalton, shows that gases tend to intermix, and 
that, however different their nature, when two of them are placed in contact, 
they become as one body. Thus, one vessel filled with hydrogen was placed 
two or three feet above a similar vessel, which was filled with carbonic acid 
gas. A small tube connected these two vessels. " In the course of a few hours, 
hydrogen," although it was much the lighter substance, " was detected in 
the lower vessel ; and carbonic acid," which was much the heavier gas, was 
detected "in the upper; after a still longer time, these gases were found 
perfectly and equally mixed" in each of these two vessels, thus separated. 

Upon this principle, the carbonic acid gas which passes from the lungs in 
expiration does not fall to the floor by force of its own superior weight, but is 
diffused through the air of the room, and rises at first toward the ceiling with 
the warmer and lighter air and vapour that come from the lungs. Consequently, 
the ventilating flues, which carry the foul air away from an apartment, may 
open at the lower or the upper side of the room. 

The physical properties of the atmospheric air, its weight and motion, 
winds, moisture in the air, clouds, electricity, and the relation of these to ani- 
mals, are described at length in an entire chapter. 

Dr. W. explains as much of the anatomy and physiology of respiration, the 
relation of the air to the blood, and of the changes effected in both the blood 
and the air by being brought into contact in the lungs, as is necessary to con- 
vey a general understanding of his main subject, and to show the constant 
necessity of fresh air for respiration, and the means of obtaining a con- 
tinued supply in all inhabited apartments. 

All artificial lighting is produced at the expense of the purity of the air. 
In the combustion of oil, tallow, gas, wax, &c, oxygen is consumed, and car- 
bonic acid and water are produced, and thus the air is vitiated. Ventilation 
cannot be perfect, unless these effects are taken into consideration, and fresh air 
provided for the candles, lamps, and gas burners, as well as for the lungs, and 
the products of combustion, as well as those of respiration, removed. 

Chapters VI. and VII. treat of all the various forms of vitiated air to which 
men may be exposed, and describe the effects on health and life from carbonic 
acid, carbonic oxide, sulphuretted hydrogen, sulphurous acid gas, chlorine, 
miasma, smoke, dust, and other mechanical impurities in the air. The means 
of removing these impurities, and of preventing their effect upon the animal 
constitution, are described in the next chapter. Ammonia, the common emana- 
tion from diseased bodies, may be neutralized by evaporating acids in the room. 
Hence we see the propriety of the frequent practice of pouring vinegar on a 
hot iron in the chambers of the sick. Carbonic acid may be removed by caustic 
earth or lime in the form of whitewash. For this purpose, lime must be fresh," 
as old lime is presumed to have already absorbed carbonic acid to its full capa- 
city. Rooms, therefore, need frequent white-washing. Sulphurous acid is 
absorbed in large quantities by water. Sprinkling the floor answers this pur- 
pose. Chlorine acts as a very powerful disinfecting agent by combining with, 
or decomposing, the fetid gases, and neutralizing them. 

It has been long a desideratum to find some means to be relieved of the 



132 Reviews. [July 

smoke of chimneys. " The term smoke, applied in common language to any 
sooty exhalation or steam, includes a great number of products, ever varying 
according to the nature of the materials from which it proceeds, and the man- 
ner in which these materials are subjected to the action of heat and air, and 
mingled with other substances. 

u Black smoke consists essentially of carbon, separated by heat from coal or 
other substances, with carbonic acid and carbonic oxide ; if the heat accom- 
panying its production is great, the carbon forms a very loose and powdery 
soot ; if less, the larger amount of the following substances : carbon, water, 
resin, oily and inflammable products of various volatilities, ammonia, carbonate 
of ammonia." — Wyman's Treatise, p. 91. 

The smoke of bituminous coal is black, and contains sulphuretted hydrogen; 
and, when the draught is powerful, minute fragments of coal are separated 
and carried out with it. The smoke of wood contains water, carbonic acid, 
and pyroligneous acid. This last " acid produces the irritated and inflamed 
state of the eyes when exposed to smoke. In cold weather, especially, when 
this acid is formed in air-tight stoves, at a low temperature, it is condensed upon 
the bricks of the chimney, and, uniting with the lime, forms an acetate of lime, 
which is soluble in water, and, being gradually removed by the rain, nothing 
remains between the bricks but sand." — Wyman's Treatise, p. 93. 

The smoke, unless carried away and diluted in the upper regions of the 
atmosphere, or consumed, is, at all times, injurious to health. When bitumi- 
nous coal is consumed, and especially for manufacturing purposes, as in furnaces, 
and even for ordinary fires of houses, shops, &c, the black flakes of soot pass 
off from the chimneys and float in the atmosphere. This matter then falls 
upon the roofs of buildings, and on everything else that is exposed to it. It 
enters houses, covers furniture, and soils clothing. In places where this coal 
constitutes the principal, or the only fuel, as at Pittsburgh, Cincinnati, Wheel- 
ing, or Louisville, &c, the whole atmosphere is very sooty, and everything is 
subjected to its influence. The rain-water that is caught from the roofs, espe- 
cially after an interval of dry weather, is very black, so that it is impossible 
to wash linen perfectly white with it. 

" Over London, in calm weather, the smoke hangs like a cloud, and when 
there is a wind, it is drawn by it into a stream extending twenty or thirty 
miles from the city." — Wyman's Treatise, p. 91. And wherever this soot is 
carried in the atmosphere, it enters the nostrils and penetrates the lungs, and 
it must irritate more or less the delicate mucous membrane of the air passages. 

The soot, metallic vapours, and other sublimated matters of smoke, can be 
precipitated by sending the column of smoke through an artificial shower of 
water, which takes up all these offensive impurities. This process of cleansing 
smoke may be made a matter of economy, as well as of health and comfort. 
One witness states that, " by this arrangement, he was able to save in the form 
of lamp-black about one-twentieth part by weight of the coal consumed." — 
Wyman's Treatise, p. 102. 

A great many plans have been invented for the combustion of smoke ; but 
those only are successful which admit a certain portion of air, heated to a pro- 
.per temperature, to the column of smoke, after it has passed from the fire. In 
combustion of fire, most of the carbon and hydrogen unite immediately with 
oxygen, and form carbonic acid and water; the rest passes off with the smoke; 
but if, immediately after passing from the fire, they come in contact with more 
oxygen which is heated, they are consumed. 

Admitting the necessity of pure air for health, it can hardly be doubted, 
that no one should be suffered to throw smoke or other impurities upon the 



1849.] Treatises on Ventilation. 133 

atmosphere we breathe. Dr. Wyman "questions whether any manufacturer 
or corporation should be allowed to produce such an amount of evil" as arises 
from smoke and soot, "while ways exist of effectually preventing it." — Treat- 
ise^ p. 91. The question applies equally well to all the manufacturing or 
chemical processes which send forth noisome emanations, gases, or dust. These 
are public nuisances, and ought to be prohibited by public authority. The 
noxious emanations from the drains and sewers of cities, loaded with the 
destructive sulphuretted hydrogen gases, certainly come under the cognizance 
of public authority. But, in most cases, and, we fear, almost universally, 
they are allowed to flow forth from the vent-holes of the sewers, and to spread 
themselves in their neighbourhoods, to offend and injure all who are compelled 
to breathe them. 

It is somewhat singular that city governments, while they are so careful to 
drain all the waste and foul fluids from their streets and houses, should not 
also feel the obligation to prevent or remove the gaseous emanations from 
those drains, because these are equally destructive of the health of the people, 
and even more injurious to the property in their vicinity. 

It was our original purpose to speak of internal ventilation, or that of 
houses, halls, shops, &c, rather than of external ventilation, or that of streets, 
towns, &c. We therefore return to a consideration of the necessity of fresh 
air, and the means of supplying it to all the rooms which are occupied by 
human beings. 

A certain portion of the oxygen of the air is consumed at every inspiration, 
and the unconsumed air is returned from the lungs, in connection with carbon 
and hydrogen, in the form of carbonic acid gas and vapour. Oxygen, in these 
new combinations, cannot serve the purpose of respiration. Air, then, which 
has passed into and out of the lungs, has not only lost a part of its life-giving 
oxygen, but is loaded with gases that are injurious to life. 

Only about one-quarter of the oxygen of the air which is inspired, is con- 
sumed by passing once into the lungs. But this respired air, having only fif- 
teen or sixteen per cent, of oxygen, cannot so well purify the blood as that 
which has twenty or twenty-two per cent, of oxygen. Air, when weakened, is 
not so effective as when it is of full strength, and, therefore, it should not be 
breathed more than once. 

Should the expired air be at once carried out of the apartment where it has 
been breathed, and its place supplied with pure air, and should the air of the 
room be corrupted by no emanations from the skin, &c, a person would need 
to be supplied with only about as much as he inhales eighteen or twenty times 
a minute, or about eight hundred cubic inches a minute. But, as the expired 
air, weakened by loss of its oxygen, and loaded with offensive and noxious 
vapours and gases, is diffused through the room, and mixed with the pure air, 
the whole is somewhat weakened and vitiated. It is therefore necessary to 
supply fresh air in much larger quantity than the amount that is actually in- 
spired. 

Upon the question of what quantity is necessary to be supplied, authors 
differ widely. Tredgold thinks four cubic feet per minute sufficient, while Dr. 
Reed sometimes supplies the House of Parliament with more than sixty feet 
per minute for every occupant. None will doubt that, in proportion as the 
air is pure, the respiration is perfect; and that, in proportion as the blood is 
relieved of its waste particles, and fitted to nourish the body, the tone of life 
is high, and all the functions, so far as the blood is concerned, are performed 
with ease and energy. 

Taking these principles into consideration, and remembering that the ex- 



134 Reviews. [July 

pired air in any apartment mixes with that which is yet to be inspired, the 
sixty feet, given by Dr. Reed to the members of Parliament, are better than the 
four feet proposed by Mr. Tredgold. Dr. Reed says that ; whenever less than 
this quantity was received, the difference was perceptible. But, unfortunately, 
the sensibilities of those who occupy a close room, become so dull from a 
deficiency of oxygen, that the foulness, and often the stench of the air which 
such persons breathe, are not perceived. We have frequently entered school- 
rooms in which the air was very offensive to our lungs, and yet those who 
had gradually become accustomed to this corruption and waste, did not com- 
plain of impure air, and sometimes they failed to perceive it. In such rooms 
the occupants can live, even without suffering pain; but their life is low, and 
their energies, both of mind and body, much reduced. 

The only question in this matter should be, not with how little air one can 
barely retain life and even ease, but how much will increase his powers and 
elevate his tone of life. 

Nevertheless, in the present state of architectural science, we do not expect 
that any arrangements will be made to supply, even to public assemblages of 
legislators, or to courts, a quantity of fresh air anything like that which the 
members of Parliament receive. So long as the questions relative to mo- 
ney and expense retain their present paramount importance over questions 
relative to life and health j so long as principles of economy are universally 
studied and followed, while the principles of physiology are generally un- 
known and disregarded, we have no reason to expect that more than ten cubic 
feet will be supplied per minute to each occupant of a room, even by the few 
who intend to produce what they deem a proper supply for themselves, their 
families, and workmen. 

How due ventilation shall be effected ; how foul air shall be carried away, 
and fresh air shall be supplied to apartments, are questions that have occu- 
pied most of the attention of writers on ventilation; and the descriptions of 
the various methods by which these objects are effected, fill the greater part 
of their books. More than two-thirds of Dr. Wyman's treatise is devoted to 
this topic. 

Very few occupied apartments are ventilated at all; that is, there are no means 
designed and prepared for the admission of fresh, and the removal of foul air. 
If such rooms were air-tight, their occupants would suffocate. Fortunately, the 
imperfections of the builder compensate, in some measure, for the omission 
of the architect; because few rooms are made so tight as completely to pre- 
vent the ingress and egress of air. 

Most rooms have a fireplace which serves as an outlet for foul air, and afford 
facilities, through undesigned crevices of the doors, windows, and walls, for the 
admission of fresh air. This unavoidable ventilation is generally sufficient; at 
least, it gives a tolerable atmosphere to the rooms, especially when the fire- 
place is so large as to carry off large volumes of air with the smoke. 

But the introduction of stoves, by means of which the throat of the chim- 
ney is narrowed, and the draught hole in the stove door so diminished as to 
admit only sufficient air to support the combustion of the fuel, prevents the 
free escape of the foul air that would pass off through the open fireplace. 
The air-tight stove, especially, inasmuch as it is intended to admit only air 
sufficient to support combustion in the lowest possible degree, and to allow 
none to pass off with the smoke, presents a most effectual obstacle to ven- 
tilation. It is designed to warm only as many cubic feet of air as the room 
contains, with the addition of the small quantity that is needed to support the 
mere smouldering of fuel. It therefore prevents the escape of any warmed 



1849.] Treatises on Ventilation. 135 

air, and provides for no loss of heat, except by radiation through the windows 
and walls of the room. The air-tight stove may be considered as a valuable 
invention for the economy of fuel; but for economy of health and strength 
and productive power, it is a most unfortunate invention, and ought never to 
be used by those who desire to sustain the highest measure of life. We are 
glad to see that the use of these stoves is diminishing ; and that many of those 
who still retain them, use them as common draught stoves, thereby obviating, 
in part, at least, the objections which we have made to them. 

Most rooms are ventilated, in the summer, by opening the windows. When 
the. rooms are loosely built, and there is a powerful draught through the 
fireplace, there is a sufficient opportunity for the ingress and egress of air • and 
no farther ventilation is needed, while the fire is burning, in winter. But 
rooms heated by stoves need other means to carry off the foul air, even when 
the fire is burning; and, during a certain period of the autumn, and of the 
spring, when there is neither fire on the hearth, nor open windows, all rooms 
need special means of ventilation. 

Perfect ventilation includes both the admission of fresh, and the removal of 
foul air. But most plans of ventilation include only one of these processes, 
Some houses receive a supply of fresh air through a furnace, and some have 
ventilating flues to carry off the vitiated air. In the former case, foul air is 
left to the chance of escaping from the rooms through accidental outlets, or 
unavoidable crevices, while fresh air enters through the same channels. When- 
ever fresh air is admitted by design, it is commonly, for the purpose of warm- 
ing merely, through the furnaces, ventilating stoves, &c. 

There are, however, two kinds of ventilation in use : one, called the vacuum 
ventilation, which draws the foul air out, and the other, called the plenum ven- 
tilation, which forces the fresh air in. The former is in much the most fre- 
quent use. In some buildings, both are combined, and, in this case, ope- 
rate most successfully. Indeed, it is only when they are thus combined, or 
when some substitute is provided for the other, that either can operate with 
sufficient success. 

A vacuum cannot be created in any room, and its air cannot be compressed. 
Foul air cannot be drawn out unless fresh air is admitted to take its place ; 
neither can air be admitted through a furnace, or through any channel, un- 
less that which is already in the apartment passes out. 

We know of buildings so tightly built that little or no opportunity is left 
for the air either to enter or to escape. These buildings the owners attempt 
to warm with furnaces without success. The furnaces are well made, and 
adapted to their situations and purposes ; their fires burn well, and there is 
sufficient open communication from without to the warm air chambers, and 
from these chambers to the apartments that are to be heated. But the air 
does not flow from the warm air chambers to these apartments, and for this 
plain reason, that these apartments are already filled with air, and can admit 
no more, unless some of that which is already there can escape ; jfor this, there 
is no opportunity, either through any ventilating flues, or through any crevices 
of imperfect joiners' work. The opening of a flue through the upper ceiling 
would remedy the difficulty, and then the furnaces would work well, and sup- 
ply the needful quantity of fresh and warm air. 

On the other hand, some apartments, which are built with similar tightness^ 
are furnished with ventilating flues ; these are designed to carry off the foul 
air. But no foul air flows through these flues, because no provision is made 
for the admission of fresh air, nor any undesigned apertures left, through 



136 Reviews. [July 

which it may find its way. As no vacuum can be created, these ventilators are 
useless. 

A special apparatus is employed for plenum ventilation. Air is usually 
brought from without by means of a revolving cowl, which always presents 
its open mouth to the wind, and communicates by pipes with the apartments 
that are to be ventilated. The pressure of the wind, when in motion, forces 
the air into the room. 

The same object is also effected by the revolving fan, which communicates 
at its axis with the external air, and from its circumference with the inside 
of the house. A familiar example of this fan is seen in the common win- 
nowing mill, which is used to separate the chaff from grain after it is threshed. 
The fan consists merely of an- axle, to which several flat pieces of board or 
leaves are attached, like the spokes of a wheel, having their surfaces paral- 
lel with the line of the axle. This fan is enclosed in a hollow, cylindrical 
box, which has only two apertures, one at the centre of its ends, or the axle 
of the fan, and the other at the circumference. When the fan revolves, its 
leaves drive the air outward from the circumference and through the aperture 
which is there made. This centrifugal force leaves a diminished pressure at 
the centre of the fan, and the air is then pressed in through the hole at the 
axle. Thus, there is a current of air created through this central aperture of 
the cylindrical box, and thence through the aperture at the circumference ; and 
this current can thus be directed in any course through proper pipes. When 
the fan is in motion, the air is driven by the centrifugal force through the 
pipe that leads from the circumference, and its place is supplied by other air 
through the aperture at the axis, and thus a continual current of air is drawn 
in through the one, and forced out through the other. An air-pump of suf- 
ficient size is sometimes used to force the air into buildings. Both of these 
plans require a motive power to keep them in action j but this is very expen- 
sive, and, except in factories where it is created for some other purpose, gene- 
rally unattainable. They, therefore, can never be brought into general use. 

The most common means of supplying fresh air is the furnace, which answers 
the double purpose of warming and ventilating. By heating the air, it gives 
it a motive power, and causes it to ascend by means of its specific levity. 

An objection to the common furnaces is, that they heat the air too much, 
and deprive it of its moisture. When the air is brought in contact with red- 
hot iron, or even in contact with that heated nearly, though not quite, to redness, 
it is rendered less comfortable to breathe, and less fit to effect the purposes of 
respiration. The apartment is not so well warmed, when the heat is thus con- 
centrated in a small quantity of air, as when it is more diffused ; and a much 
larger quantity of air, raised to a lower temperature, is sent into the room. 
In the former case, the heated air ascends directly through the register to the 
upper parts of the room ; there a portion of it finds its way through the cre- 
vices, and the rest flows along the ceiling, and thence down the walls and 
the windows, where, becoming cooled, it falls towards the floor ; the current 
then moves towards the register, whence it is again carried upward. Thus 
directly over the register, there is an ascending current of very hot, and 
sometimes intensely hot air, and at the sides of the register, a current of cooled 
air; therefore the room cannot be otherwise than comparatively slightly warmed. 

This evil may be remedied by having the air heated, not by an iron pot 
filled with coals or flame, but by steam or hot water, and sent in large quan- 
tities, not through a single flue and aperture opening from the floor into the 
apartment, but through the lower part of the side walls, which may be pierced 
with a great many small holes. By this means, the air is not heated to a 



1849.] Treatises on Ventilation. 137 

disagreeable degree, but only to a comfortable temperature, and it enters the 
room in such a manner that it gives the atmosphere, in every part, an agree- 
able and healthy warmth. 

The air in inhabited rooms in the temperate and. northern climates is neces- 
sarily made warmer, during most of the year, than the open air; and there- 
fore tends to rise and escape through any aperture in the upper part of the 
rooms. Even in the same room, the warm air rises to the top ; and, when 
not disturbed, it arranges itself in horizontal layers, the warmest being at the 
top, and the coolest at the bottom. Some observations are recorded in the 
Annales oV Hygiene, in regard to the temperature of a room twenty-one feet 
high which was heated by a stove. Thermometers were hung at intervals of 
about two feet, from the floor to the ceiling. These indicated successively the 
temperatures of 65°, 67°, 70°, 72°, 75°, 80°, 81°, 86°, 90°, 94°. 

This specific levity of the air is generally relied on to create the vacuum 
ventilation, and carry the foul air from apartments. Many ventilators are, 
therefore, merely tubes leading from the upper part of the rooms upwards, 
and through the roof to the open air. When the internal air is warmer than 
the external air, there is a constant upward current through these flues, and 
this current moves with a rapidity proportionate to the difference between the 
external and internal temperatures. But when, in the summer, and in warm 
climates, the rooms are not warmed, and have the same temperature as the 
atmosphere without, there can be no upward current from this cause. In such 
cases, other means must be used to facilitate the passage of air out of inha- 
bited apartments. 

For this purpose, three forces are resorted to : the exhausting fan ; heat 
in some form, applied to the air in the ventilating flue ; and the moving cur- 
rent of air passing over the top of the ventilator. 

The fan can be used by conducting the flue from the apartment to the cen- 
tral aperture near its axis ; when the fan revolves, the air is thrown out from 
its circumference by the centrifugal force, and its place supplied by air of the 
room drawn in at its axis. This is a very effectual method of drawing air from 
any room; but as a constant power is required to keep the fan in motion, it 
is rarely used. It can never be extensively applied in dwellings and shops. 

Heat may be easily applied directly to the ventilating flue. By warming 
the air within it, an upward current will be created. In some cases, all the 
flues in one house lead directly or indirectly to one larger tube, or chim- 
ney, in which a fire is kept burning. This causes an upward current, and a 
draught from below sufficient to draw the air through all these'channels, and to 
carry off the foul air from the rooms with which they are connected. This 
fire is generally placed in the flue at the attic, or upper chamber ; and in this 
position, it works with the least trouble and best results. Sometimes it is 
placed at the bottom of a flue on the ground ; and the flues from the various 
rooms, turning downward, open into it. 

It is not convenient, nor do we suppose it will ordinarily be considered 
practicable, in common dwelling-houses, to adopt either of these plans. Either 
would involve more expense, both of original construction and of subsequent 
maintenance, than people — even those who admit the necessity of ventilation 
— are usually willing to bear. 

This difficulty might be obviated, in part at least, by having the ventilat- 
ing flues connected with, or made in the chimney immediately contiguous to, 
the fire and smoke flues. This is applicable to rooms used, in the winter, only 
during daytime. The heat of the fire and smoke would warm the air of the 
ventilating flue sufficiently to create an ascending current and a draught from 



138 Reviews. [July 

the room, while the fire is burning. But in the night, when there is no 
fire, this means would fail ; and sleeping chambers, which need purification 
even more than rooms occupied during the day, cannot thus be ventilated. 

An Argand lamp, burning in the ventilating flue, will produce sufficient 
draught, in most cases, to ventilate a single room, if it is occupied only by a 
few persons. But when the room is large, and filled with many occupants, it 
is to be feared, with reason, that this means will not create a current sufficient 
to carry off all the foul air as fast as it is generated. 

A very easy and cheap method of ventilation by means of the heated cur- 
rent, is to open a passage from the room directly into the chimney, above the 
fireplace, and to place in this hole a tube with an arm several feet long, turn- 
ing upwards in the smoke flue. This, being heated by the smoke and fire, 
creates an upward current and a draught from the room, though not so strong 
and effective as in the longer flue, which extends from the room quite to the 
outward air. 

The currents of the external air, or the wind, is the moving force, whose 
aid is most commonly depended upon in the ventilation of buildings. This 
is used on the principle that one current of air carries with it, or absorbs, 
other air with which it comes in contact. Thus, a current passing over a 
chimney top, or the open end of a ventilator, takes up and carries along with 
it the upper stratum of air in its flue ; by creating a vacuum, or by dimin- 
ishing the atmospheric pressure in its upper part, it causes an upward current 
from below, and thus a draught is established or increased through the chim- 
ney and ventilator. 

To effect this purpose, a great variety of forms of ventilators and chimney- 
tops have been invented. All have a tube, or flue, through which the smoke 
from the fire, or the air from the rooms, ascends; but they have tops or caps 
of various forms and structure, to allow the external horizontal currents to 
strike most favourably upon the ascending internal currents, and aid their 
passage outward most effectually. 

Espy's ventilator consists mainly of a vertical cylinder or ascending pipe, 
and a hollow cone, with a closed apex and open base, placed horizontally on 
its top. The cone stands and revolves horizontally upon a vertical shaft or 
pin, which rises from the middle of the ascending pipe. 

The upper end of the vertical pipe does not open directly into the air, but 
passes through a hole in the under side of the cone, so that all the smoke 
from the chimney, or all the air from the ventilating flue, goes from the as- 
cending pipe into the hollow cone, and through its open and larger end to the 
external air. The revolving cone is supplied with a vane, so that it always 
stands in the direction of the wind, presenting its closed apex to the windward, 
and its open base to the leeward. 

When the atmospheric current strikes upon this cone, it is divided at the 
apex, and follows the spreading sides; having passed these sides, it con- 
tinues in the same direction. In this way it leaves a vacuum, or, at least, 
a diminished pressure of air in the space immediately at the leeward of the 
base. The air from within the cone and the vertical pipe rushes into this 
space, and is thence carried away with the wind, and thus an upward current 
is created. 

A more simple plan, and one much less liable to get out of order, is that 
of Mr. Emerson, of Boston. This consists of the upright cylindrical flue, 
or shaft, which is surrounded at the top by the hollow section of a truncated 
cone. The diameter of the smaller end of this section is the same as the 
diameter of the upright flue, and the circumference of this smaller end is 



1849.] Treatises on Ventilation. 139 

placed uppermost, and attached to the circumference of the flue. The larger 
end of the cone is downward, so that the sides of the section spread outward 
and downward. When the air is moving, that stratum which strikes against 
the sides of the cone is directed upward on its inclined plane, and, continuing 
in the same direction, it passes over the open mouth of the vertical tube, and 
leaves a vacuum, or a space, of less compression between its current and the 
mouth. This produces the same effect on the air in the flue or chimney, and 
causes a draught through them in the same manner as Espy's ventilator. 

To prevent downward currents from the atmosphere, a cap is placed several 
inches above the top of this open mouth, supported by several iron rods suffi- 
ciently strong to sustain it, but not large enough to interfere with the wind. 
Its diameter is about the same as that of the larger end of the truncated cone, 
or nearly twice as large as the diameter of the main ventilating tube or chim- 
ney flue. 

This ventilator is made in such accordance with the principles of natural phi- 
losophy, that its form has suggested itself to several persons who were study- 
ing the subject of ventilation in various countries and at different periods. 
Count Cisalpin, in France, invented it more than seventy years ago. It was 
again brought forward by St. Martin, a French naval officer; and within 
two years, it was brought into use once more by Mr. Frederic Emerson, in 
Boston, and is now extensively used in that city and its neighbourhood. Dr. 
Bell says, "that most of these ventilators have been invented and re-invented 
every few years." — On Ventilating Buildings, p. 73. 

This ventilator is improved by spreading the mouth of the flue so as to give 
it a conical form, or by placing on its top a hollow truncated cone, the smaller 
diameter of which is the same as that of the other cone and of the cylindrical 
flue. In this case, the end of the cylindrical flue and the smaller bases of the 
truncated cones are of the same size, and are joined together; the lower cone 
spreads downward and outward, while the upper cone spreads upward and out- 
ward. The height of the upper cone, and consequently its longer diameter, 
are much less than those of the lower cone. 

There are many other forms of ventilators, but all depend on the principle 
that " air in motion communicates motion to those portions of air at rest in its 
immediate vicinity/' and that when air in motion strikes upon any object, its 
current is divided, and leaves a space of diminished pressure on the opposite 
or leeward side of the object. When the wind passes over the open mouth 
of the ventilator or chimney, its current communicates motion to the air within 
these tubes, and causes a current upwards ) and if an ascending current is 
already in the tubes, but less rapid than the wind, it is increased. 

When the tops of ventilating tubes or chimneys are surrounded by a cone, 
or a plane inclining downward and outward from the upper edge of the tube, 
the stratum of moving air, that would Otherwise strike directly against the 
upper part of the tube, strikes against this inclined plane or cone, and is turned 
upward and over the open mouth, leaving a space of diminished pressure be- 
tween itself and the tube. The air is thus pressed upward to fill this rarer 
space, and then a more rapid upward current is created through the tube. 

The committee of the American Academy submitted all or most of the 
various forms of ventilators to the test of rigid experiment, and ascertained 
their effect upon a current of air in a tube, on the end of which they were 
successively placed. Dr. Wyman took a long pipe, which represented the 
smoke or ventilating flue, and, by means of a revolving fan, he created a cur- 
rent of air through the tube from its circumference : this current represented 
the wind. The end of the long pipe was placed in the mouth of the fan tube, 



140 Reviews. [July 

and at right angles to it; the open end of the former was in the middle of 
the mouth of the latter, so that the current from the fan, or the wind, struck 
perpendicularly upon the pipe or ventilating flue, and a part of this current 
passed over its mouth. By means of this apparatus, Dr. Wyman was enabled 
to throw a current of air, with a regular and determined velocity, through the 
fan tube upon the end of the long pipe j and by other means, he was able to 
measure the velocity of the current that was induced through the long pipe. 
Models of the several kinds of ventilators were placed successively upon the 
end of the long pipe, and each one was exposed to the wind from the fan. 
The various velocities of the current, thus induced through the long pipe, 
when the different ventilators were placed upon it, were taken as the mea- 
sures of the power of their several ventilators in creating a draught through 
any chimney or flue. 

The principles on which these experiments were made, and the details of the 
several processes, are described in the published Report of the Academy, 
and thus we have the record of the efficiency of the various kinds of venti- 
lators. In all these experiments, the current from the fan, or the wind, was 
the same; the only difference was in the velocity of the current through the 
long pipe or the ventilating flue. 

The rate of the current through the long, or ventilating tube, when capped 
with Espy's ventilator, was 1.29 feet per second; with Emerson's ventilator, 
the side of the cone having an inclination of 45° to the base,* 1.61 feet per 
second; with the same, having an inverted section of a cone above, as before 
described, and the sides of the lower cone having an inclination of 52° to the 
base, 2.16 feet per second. Dr. Wyman says, "This is one of the most ef- 
ficient fixed ventilators with a cap which have been examined by the commit- 
tee." — Report to the Academy, p. 13. 

We have not space, nor would it be useful, to describe all the ventilators 
which were thus tested by this committee of the Academy. Suffice it to say, 
that those we have mentioned are the best, and in most general use. But to 
those who wish to pursue the matter farther, we commend the Report of the 
Academy. 

Dr. Bell's work, being simply an address, does not cover the whole ground of 
the various plans of ventilating and warming. Its sole object is to explain 
the leading principles, and to show some of the best practical methods, of ven- 
tilation; it is therefore limited in its descriptions. Preliminary to the main 
subject, Dr. Bell considers the hygienic influence of foul and pure air, and 
shows the serious results which inattention to proper means of purification pro- 
duces, as well as the advantages which result from a due appreciation of its 
importance. Dr. B. justly and eloquently deplores the general neglect of 
ventilation, and attributes it to the true cause— the general ignorance of the 
necessity of fresh air in all apartments that are occupied by breathing beings, 
and the consequent omission of all provision for the supply of pure air. Our 
whole system of architecture for public and for private purposes, for churches, 
factories, dwellings, and shops, however much improved in elegance and con- 
venience, has not admitted the necessity of ventilation even as a general law. 
It is occasionally admitted. Some churches, school-houses, public halls, court- 
rooms, and a few dwelling-houses, are ventilated. Some factories of the most 
recent structure, a very few jails, and, rarely, a workshop, are provided with 

* The dimensions of the original of this model: Diameter of the flue, 18 inches; of 
the cone at the larger and lower base, 3 feet 6 inches; of the plate, 3 ft. 6 inches; height 
of the cone, 12 inches; height of the plate above the top of the cone, 9 inches; thickness 
of the plate, 1^ inch. — Note to Report to the Academy, p. 17. 



1849.] Treatises on Ventilation. 141 

means, to a greater or less extent, for the admission of fresh, and the removal 
of foul air. But scarcely any private dwellings, parlours, lodging rooms, or 
kitchens ; scarcely any places, whether public or private, in which men and 
women stay, for business, for study, for domestic occupation, or for enjoy- 
ment, are provided with means for the supply of pure air. 

Dr. Bell, in a single paragraph, shows how strikingly this neglect of what 
is necessary to support life is combined with the power and willingness to pro- 
vide everything else. " A few men of giant energies, of boundless faith, of far- 
seeing calculation, sit down in the counting-rooms of this city, with a survey- 
or's sketch, and a few engineers' levels. They decide that a town shall be 
built—a manufacturing city erected. Straightway, and almost like the chang- 
ing scenes of the theatre, huge brick palaces arise, streets in long perspective 
of shops, schools, houses, side-walks, begin to stretch themselves out from a 
thousand nuclei, to meet the new formed elements in exact symmetry, like the 
points of ossification in the growing embryo. Churches point their spires to 
the skies in all the beauty of Grothic tracery, or plant their firm columns of 
stone in all the solidity of Grecian art. In short, what the conquerors of the 
world have been lives and centuries in designing and accomplishing, is called 
into existence by our merchant princes, almost with the wave of Prospero's 
wand!" — On Ventilating Buildings, p. 18. 

In these and other cities, almost everything is provided but fresh air. The 
people have sufficient food, heat and clothing, while the labour of operatives 
is amply remunerated ; but economy in air is carried to an extent which, if 
applied to food, would be called meanness. We have obtained the size of the 
rooms of several boarding-houses in some of the manufacturing establishments. 
These differ among themselves, but there is generally an unhealthful economy 
of space, both in the rooms which are occupied for sleeping apartments at 
night, and in those which are used as dining and sitting rooms by the operatives 
during the day. One chamber, with 262 £ cubic feet of air, is occupied by 
two lodgers. Another, with 500 feet, has four lodgers; and an attic, with 
769 feet, has six lodgers. Some portions of this space are occupied by beds, 
trunks, and other furniture; but making no deduction for them, the oc- 
cupants of these rooms respectively have each 131, 125, and 128 feet of air 
for the whole night. In other rooms, two lodgers have 385 feet; four have 
778 feet; two450; eight 2137; four 1080; eight 2577; four 1414; four 1800; 
four 1803; and two 990 feet. These are more liberally supplied. But even 
the best affords only 495 feet of air for each person, which is but a pittance 
compared with what these lodgers need for their respiration. Taking Tred- 
gold's, the lowest estimate of the quantity of air which is necessary to support 
respiration, each person consumes four feet every minute. Upon this estimate, 
the best of these rooms has a supply of air sufficient to last its occupants one 
hundred and twenty-four minutes, and the worst enough for thirty-one minutes. 
But, according to the better estimate of Dr. Reid, they have only air enough 
to support their respiration thirteen minutes in the most crowded, and fifty 
minutes in the most favourable rooms. 

These persons are supposed to remain in their chambers seven to eight hours, 
and some even longer. Notwithstanding the limited supply of air in these 
rooms, and the number of occupants, no means are provided for ventilation. 
If the rooms were as air-tight as they were intended to be, suffocation must 
take place in all, the best as well as the worst, with the only difference that 
this event would happen earlier in some cases than in others. Happily for the 
lives of these lodgers, it is almost impossible to make a room so tight as to 
prevent entirely the passage of air through its walls, windows, and doors ; 
No. XXXV.— July, 1849, 10 



142 Reviews. [July 

the imperfection of the joiner's work thus, in some degree, compensates for 
the imperfections of the architect's plans. 

The day rooms of these boarding-houses are no better • and when most 
crowded, they are even worse than the lodging rooms. One room, which is 
occupied as an eating and sitting room by twenty-five boarders, contains 1530 
cubic feet, and in another room thirty boarders have 1904 feet of air. Except 
for the short time allowed for eating, it is presumed that the whole family will 
not be in those rooms at the same time. But they have no other room to sit 
in, except their sleeping apartments, and these are rarely warmed by fires. It 
is, then, a reasonable supposition, that, in winter and in stormy weather, the 
boarders, when not employed in the mills, spend most of their time in these 
sitting rooms. 

The mills, except when the ten hour system is adopted, are usually in opera- 
tion twelve hours a day. Twelve or fourteen hours a day are thus left to be 
spent elsewhere. Making due allowance for the time required to pass be- 
tween the mills and the boarding-houses, to walk abroad, and to visit, there 
will still be left some hours of every working day, and a great part of 
Sunday, to be spent in a crowded sitting room, besides the entire night in 
the crowded sleeping chamber. 

While these operatives are at work, they usually have sufficient air. Most 
factories are large, airy, and elegant, while some are even magnificent. In 
these, everything is prepared to make the working men and women comfort- 
able and cheerful. But when they leave their ample halls of labour, and go 
to their resting places, they exchange freshness, and airiness, and liberality in 
arrangements for comfort and life, for the close and offensive air of narrow 
apartments, and economy, even parsimony, in the means of life. 

The projectors of these establishments design that they shall be conducted 
with due economy. They understand that the economy which gives to the 
labourer everything necessary to make him healthy and comfortable, is no less 
profitable than liberal. Still, as we have before stated, while no reasonable 
complaint can be made against the food, clothing, and the remuneration of 
operatives, or against their working places, the size of their rooms, and the 
insufficient degree in which air is supplied, indicate an economy which is not 
only misapplied, but which degenerates into parsimony. 

Dr. Bell, after giving a slight notice of the various ventilators in common 
use, which depend upon the specific levity of the warmer air of the rooms for 
its removal, or upon the wind for its outward current, dismisses the whole by 
stating, that all these are very uncertain and insufficient means of removing 
the foul air from, or of supplying fresh air to, enclosed apartments. " With 
respect to all the hundred varieties of contrivances of the turn-cap or cowl 
order, their whole consideration may be briefly dispatched in simply observ- 
ing, that their utility is wholly dependent on a movement which frequently, 
at uncertain times and sometimes for long intervals, ceases to exist. Conse- 
quently, the ventilation of buildings depending on the winds, must be just as 
uncertain as the wind itself, and the occupants of a crowded habitation might 
as reasonably trust to the prevalence of calms and breezes in a certain se- 
quence for their food and drink, as for their air." — Dr. Bell on Ventilating 
Buildings, p. 73. 

Dr. Bell supposes that all reliable means of ventilation must include a 
motive power more efficient and regular than the wind without, or the ordinary 
temperature of the room within, and that nothing but some power especially 
provided for this purpose can effect the object. This may be done by a rotary 
fan, which, by its suction force, draws the air through its central aperture 



1849.] Treatises on Ventilation. 143 

from the apartments, and sends it off through the circumference. Or it may 
be done by heating the air of the ascending ventilating tube in various ways, 
and thus creating an upward and outward current from the rooms. The tube 
connected with the chimney does well in the winter, and for rooms which are 
heated by a fire ; but it is useless in the warm season for all rooms, and at all 
seasons for lodging rooms, where no fire is burning. The ventilating flue may 
be heated by a fire kept in it for the purpose ; or, when the house is warmed 
by the hot water or steam apparatus, a tube, containing either of these heated 
matters, by passing through the ventilating flue, will heat it sufficiently to 
create a current from the rooms connected with it. A jet of steam, thrown 
upward into the ventilating flue, will answer the same purpose; but this can 
be used only in such houses as are warmed by steam, and in factories, &c, in 
which steam power is used. 

Dr. Bell then describes at length the best plans of ventilation, and illus- 
trates them by a description of the methods by which the Houses of Parlia- 
ment, in London, the Chamber of Deputies, in Paris, the Pentonville Prison, 
near London, one of the best ventilated hospitals for the insane in England, 
and the McLean Asylum, are warmed and ventilated. 

Dr. Bell thinks, very properly, that plans both of warming and ventilating 
should be so connected, that our heat should come to us on our fresh air; for, 
the draughts of cold air, however pure, are chilling and unwholesome, and it is 
difficult to warm them by any ordinary apparatus, such as open fire or common 
open or closed stoves, in the apartment which is occupied, without occasioning 
discomfort, and often producing colds. The only exception to this is the stove 
recently invented by Dr. Clarke, and introduced into the school rooms of Bos- 
ton, which is, in fact, a furnace in the occupied rooms. It consists of a stove 
surrounded by an outer casing of sheet iron, which is considerably larger than 
the stove, and separated from it by a space of several inches. By this 
means a layer, or a hollow cylinder of air, is interposed between the heated 
stove and the air of the room, and thus the occupants are protected from the 
scorching rays of the heated iron. The chamber between the stove and the 
box is connected, by means of a tube, with the outer air, and is open at the 
top; but a cover, of blunt, conical shape, is suspended a few inches above it. 
When the fire in the stove burns, the air in the surrounding box is heated, and 
passes out at the top. The suspended top prevents its rising immediately 
upward, and gives it a lateral direction. The pure air from without comes 
into this box and is there heated, and thus the rooms are constantly sup- 
plied with warm and fresh air. 

Dr. Bell says "that all successful modes of ventilation, although they may 
differ in some principles and structure, yet agree in the following particulars : 

"They are independent of all direct lateral openings, such as windows, 
doors, &c, for the supply of fresh air. 

"They do not depend on the differences of temperature between the inner 
and the outer air for the power to remove the foul air away, nor upon any 
apertures or contrivances, operated upon by the passing currents of external 
wind, for this result. 

"They all obtain fresh air, from pure external sources, through large channels 
provided for this purpose. 

" In the cold season, this air is raised to a moderate temperature, and sent in 
large quantities into the apartments. 

" It is not sent into the rooms through a single channel, as is usual through 
common furnaces ; but through many small apertures, as through a perforated 
board in the lower part of the walls. 



144 Reviews. [July 

"And lastly, the apparatus by which the fresh air is introduced, and the 
foul air removed, is under control; so that the change of air in the apart- 
ments can be increased or diminished according to the number of occupants, 
and to their condition and wants." 

Dr. Clark's pamphlet includes two reports, which were made to the school 
committee of Boston. One shows the necessity of, and the reason for, adopt- 
ing a system of ventilation for the public school-houses in that city. The 
other report describes the plans — which were considered by the committee on 
ventilation as the best for warming and ventilating their public buildings — 
and the manner and cost of their execution. These plans are illustrated with 
good copperplate, electrotype engravings. 

In the first report, the evils of confined air, the effect of continued respi- 
ration on the air and on those who respire it, are clearly set forth, in a plain, 
simple manner, divested of scientific terms and needless explanations. Dr. 
Clark shows the gradual, though progressive, effects of air which is even but 
a little below the natural standard of purity, on children and others who 
are compelled to breathe it for a long time. Its effects are insidious in their 
approach; but they are none the less certain in their results. 

"Children, who are confined in the atmosphere of these schools, soon lose 
the ruddy and cheerful complexion of perfect health, which belongs to youth, 
and acquire the sallow and depressed countenance which might reasonably be 
expected in over-worked factory operatives; or the tenants of apartments 
which are never blest by the cheerful sun, or the reviving air." — Dr. Clark, 
on Ventilation of School-Houses, p. 12. 

But a large number of the school rooms are worse than the one above re- 
ferred to. The air in these is, generally, not merely a little below the natural 
standard of purity, but it is so foul as to be perceptible. After the rooms 
have been occupied an hour or more, the air is offensive to the nostrils, and 
oppressive to the lungs, of persons who enter them. 

It is impossible that children, breathing air deprived of so much of its 
oxygen, and so loaded with carbonic acid gas and vapour, should have pure 
blood in their arteries. With this imperfect respiration, and imperfect decar- 
bonization of the blood, the brain is supplied with impure pabulum of life; 
its energies, therefore, are imperfectly sustained; it cannot work with full 
and healthy power ; the students can neither think clearly nor study success- 
fully ; and consequently, for want of pure air, much of their time, and much 
of the expenditure for their education, must be lost. But this loss of the mo- 
ney of the people, and of the time of the scholars, is of small moment com- 
pared with the waste of strength and the blight of health produced at this 
most susceptible period of life. How many rosy-cheeked, robust, and elastic 
children enter these schools at four or five years of age, and come out at 
fifteen pale, thin, and puny ! They may not be sick, but they are far from 
being as vigorous as their earlier years promised. 

After describing these wants of the schools, Dr. Clark proposed to warm all 
the rooms by Gardner Chilson's furnaces, or, where the furnace could not be 
used, with the ventilating stoves. Chilson's furnaces have a fireplace of soap- 
stone, and a radiating surface of wrought iron, and a very large air chamber. 
Consequently, the air is moderately heated, and sent in large quantities into 
the school-rooms, and in this condition it is readily diffused throughout the 
apartments. But the old furnace, having fireplaces of brick, and cast iron 
radiating surface, and small air chambers, heated a small quantity of air to a 
degree intensely hot. This was very dry and uncomfortable, and did not 






1849.] Treatises on Ventilation. 145 

diffuse itself through the rooms, nor create an equal temperature in the vari- 
ous parts. 

Dr. Clark proposed that each room should have a ventilating duct, with 
openings both at the bottom and at the top of the walls, regulated by valves. 
All these air ducts from the different apartments in each building should 
terminate in a common duct, which should be capped by one of Emerson's 
ventilators. A large Argand lamp, or, if this is not sufficient, an air-tight 
coal stove, should be placed in each of these air ducts, to give sufficient force 
to the upward current. 

By this apparatus, Dr. Clark proposed to supply each child with ten cubic 
feet of air a minute, which is deemed a proper allowance for adults. "But 
the greater delicacy of the organization of children, and their feebler ability 
to resist the action of deleterious agents, together with their greater rapidity 
of respiration, demand for them at least an equal supply/'-— Ventilation of 
School-Houses, p. 10. 

The committee adopted these propositions, and the whole was carried into 
effect at the cost of about two hundred and fifty dollars for each of the eight- 
een grammar, Latin, and high schools; and similar improvements have been 
made in twenty-five primary school-rooms. The history and results of the 
whole work are described in the second report of Dr. Clark. 

This is a very great improvement, and worthy of all imitation. We wish 
this example to be universally followed. For this purpose, we desire that 
a copy of Dr. Clark's Report should be placed in the hands of every school 
committee of the nation; our children, then, might have an opportunity of 
strengthening and developing their minds, without wasting or deteriorating 
their bodies for want of fresh air, while they are in their school-rooms. But 
the plan of ventilation of the Boston school-houses is not perfect. The objec- 
tion still holds to the system of ventilation that depends on the wind for the 
motive power. Dr. Clark proposes, a for the purpose of compelling a constant 
action, and increasing the force of the ventilating apparatus," to have an Argand 
lamp or a gas burner, which should be put in operation whenever the wind 
should fail, or whenever the difference of outer and inner temperature should 
be insufficient to produce an ascending current. This is necessary, for the wants 
of the children are constant, while the motive power of the wind is proverb- 
ially otherwise. 

Another objection is, that the ventilator adopted in Boston is not, accord- 
ing to Dr. Wyman's experiments, so efficient as one with the double cone. 
Nevertheless, even with these deficiencies, we hold up this example to all 
others who have charge of schools and school-rooms, and bid them go and do 
likewise. 

We have already occupied so much space that we have not room to give 
an analysis of the other works at the head of this article. Mr. Toynbee's 
work is intended for the people. It is a plain description of respiration, and 
the natural relations of air and the blood, and contains several good engrav- 
ings illustrative of respiration and circulation, and of the course of the cur- 
rents of warm and cold air in heated and inhabited rooms, and of some of 
the simplest methods of ventilation. 

Mr. Toynbee proposes that some simple means be adopted to ventilate shops, 
and the common and crowded rooms of the poor. One is the substitution of 
a pane of perforated glass, or a piece of perforated zinc, or even a series of 
glass bars arranged like a Venetian blind, for one of the upper panes of a win- 
dow, for the purpose of letting fresh air in ; he also suggests that an aperture 



146 Reviews. [July 

through the upper part of the wall into the chimney, to let the foul air out ; 
he made. 

The last work which we have to notice is the "Uses and Abuses of Air." 
This is the beginning of a series of " Tracts for the People." It occupies the 
same ground as the London Tract, and describes so well the subject of its 
title, that it is a very valuable addition to popular science. It will do much 
to convince the world of the miserable economy of unventilated houses, and 
of the propriety of establishing means for purification in all our dwellings. 
Tract No. 1, or Part I., treats of the mechanism and chemistry of respiration, 
and of its connection with health and energy, and the effect of foul air upon 
both. Part II. treats of " the effect of foul air in producing bodily and men- 
tal disease } its effects at various periods of life j its influence on the general, 
physical, moral and intellectual condition of mankind. Part III., which is yet 
to come, proposes to include, Observations on the State of Ventilation in the 
City of New York ;" " and the best methods of securing a pure and whole- 
some atmosphere inside of dwellings, churches, and buildings of all kinds." 

We bid this new labourer welcome to so broad and almost uncultivated a field 
of usefulness. So extensive is the ignorance of the connection of life with air, 
and of the necessity of pure air for the support of health j so great is the 
neglect of the means by which fresh air may be secured within our places of 
abode, of labour, and of assemblage, that too many works which shall teach 
the law to the people, and stimulate them to obey it, cannot be produced. And 
to the societies under whose auspices these various tracts have been published, 
we wjsh all prosperity in the farther prosecution of their praiseworthy under- 
takings. 

There is need of light on this matter everywhere. It has already dawned 
upon the rich and intelligent j but even among them its progress has been 
meagre. They have yet to be thoroughly convinced that fresh air is not 
merely a luxury, but a thing absolutely necessary for fulness of life. 

But to the hardy children of want and toil, who are supposed to be able 
to endure any privation, and to care for no such luxury as the ventilation of 
their workshops and their homes, scarcely a gleam of light has yet come to 
show them how much more they, in their small and crowded rooms, need the 
means of procuring fresh air than their wealthy neighbours, who live in large 
houses; and to show them how much their vigour and their productive power 
depend on the air they breathe both night and day. 

This last point, the connection at all times of pure air for respiration with 
productive power, cannot be urged too earnestly upon employers, contractors, 
and labourers themselves. Inasmuch as corrupt air vitiates the blood, and 
inasmuch as vitiated blood must produce imperfect nutrition, and imperfect 
nutrition must be accompanied with impaired strength, those who habitually 
breathe a corrupt atmosphere must be less able to labour than those who have 
sufficient oxygen for respiration. Notwithstanding this fact, we know that 
economy of air is carried to a very injurious extent in regard to labourers. 
This is most observable where extensive operations are conducted; and at such 
places, the paramount object appears to be to support the labourer with as 
limited a cost of rent as possible. 

We have noticed this especially on railroads and other public works, where 
the dwellings of the labourers are put up only for a temporary purpose, and 
are therefore made of the smallest possible dimensions. We examined one of 
these shanties, and ascertained that, in an attic sixteen feet long and fourteen 
feet wide, with a height varying from at the sides to six feet and two inches 
in the centre, fourteen labourers slept every night. 



1849.] Treatises on Ventilation. 147 

In this room there were no means of ventilation, neither door, nor window, 
nor other aperture, except the cracks in the ends and roof, and a passage way 
through the floor leading to the kitchen below, in which nineteen persons ate 
and sat in the day, and five slept at night. Fifty-six cubic feet of air was all 
that was provided for each of these men ; but nature forced sufficient air 
through the cracks to save them from suffocation, though not enough to invigor- 
ate them. The labourers assured us that, when they awoke in the morning, 
they felt unrefreshed and languid ; that they had a sense of oppression about 
the breast and heart, as well as some nausea and headache, and a feeling of 
weariness in their limbs. They crawled from their beds, crept down their 
ladder, and staggered out of the door ; and some time elapsed before they felt 
clear enough in their brains and strong enough in their limbs to go to any 
work. 

If the contractors who employed these men had understood the true relation 
between life and air, they would have seen that, for want of sufficient oxygen, 
these workmen must have not only less muscular power, but less control of the 
nervous system and their muscular action ; and that, consequently, they would 
not only strike their blows with less force, and raise less with their shovels, 
but that they would more frequently strike ineffectually, and, in the end, 
accomplish so much less work, 

By the same light, the proprietors of manufacturing establishments may 
see that operatives who sleep in suffocative air must bring weaker muscles 
and duller brains to their work. The weaver, who is thus unrefreshed, has a 
slower apprehension to perceive the operations and the variations of her |om ; 
and a feebler hand to guide it; and the machinist uses his tools with less 
force, and directs them with less precision; and all come short of that full 
measure of labour which is accomplished by others whose blood is well puri- 
fied, and whose bodies are thoroughly invigorated in the night. 

Another work on ventilation which shall meet the necessities of the people, 
is yet required ; that is, a treatise which shall show the necessity of fresh air, 
and the effect of impure air on health, on fulness, and on energy of life ; which 
shall explain the principles involved in the motion of the air ; and which, 
lastly, shall describe the various means and plans by which rooms, halls, and 
workshops can be ventilated. This should be written in such simple lan- 
guage, that every builder and every carpenter may be able easily to under- 
stand it, and so well illustrated with good engravings, that no doubt can be 
left in the minds of any as to the practical application of the principles. 

This work should not be a mere tract, which may be forgotten as soon as 
read, but a volume, that shall be kept ever ready for consultation as a hand- 
book of the builder's art. This volume should yet be so small, and furnished 
at so reasonable a price, that every carpenter and mason may afford to pur- 
chase it. When this desideratum is supplied, we trust that the science of 
ventilation will be as well understood as that of warming and lighting, and 
that the means of receiving a pure atmosphere into all occupied rooms, will 
be as universally provided for as those for the admission of light and heat, 

E. J, 



148 Bevieivs. [July 

Art. XVIII. — On the Influenza, or Epidemic Catarrhal Fever of\ 847-8. By 
Thomas Bevill Peacock, M. D., Physician to the Ptoyal Free Hospital, 
&c. London, 1848: pp. 182. 

The history of epidemics is, in several respects, the most interesting object 
of study that can engage the attention of the philosophical inquirer into the 
laws of disease. These occasional maladies are displayed upon so grand a 
scale, they affect so many persons in widely distant countries and localities, 
they occur at such opposite seasons and under such various circumstances, and 
are described by so many observers from different points of view, that the laws 
which regulate them can apparently be ascertained with much greater exact- 
ness than those which govern sporadic diseases. We say apparently ascer- 
tained, because the precision of the conclusions reached in regard to epidemics, 
exists only in their generical relations. Descending to their specific forms, we 
find that they embrace types of disease the most dissimilar, and individual cases, 
again, display groups of symptoms such as are never found associated in spo- 
radic affections. But the phenomena and laws of epidemics, although thus 
removed from the nearer and more palpable domain of individual experience, 
are invaluable for correcting the inferences drawn from the study of sporadic 
affections in regard to the causes and nature of disease, inasmuch as they are 
incompatible with narrow and exclusive doctrines upon these subjects. The 
doctrine of irritation, for example, betrayed its weakness the moment it was 
testil by epidemic diseases ; for in them it was plain, even to the least ob- 
servant physicians, that the most prominent and alarming symptoms either 
bore no proportion to the local change of structure, or that they were inde- 
pendent of it altogether. 

For such, amongst many, reasons, the truthful history of an epidemic is a 
contribution to medical science of real and permanent value ; and we, there- 
fore, accept the one which is now before us with a satisfaction which is all 
the more lively that the author is, in several important respects, superior to 
those of his countrymen who have treated of similar subjects. His descrip- 
tions are deduced from " a careful analysis and comparison of the reports 
of all the cases under treatment in the Boyal Free Hospital, during the epi- 
demic, while the several particulars were still fresh in the memory." " Of 
the more severe and peculiar cases," he states that "full notes were taken 
generally every day." And the reader may judge how faithfully and fully 
the record was made, by a reference to the twenty illustrative cases presented 
in the work as examples of the different forms which the complaint assumed. 
Such guaranties for accuracy are rarely afforded by writers on epidemic dis- 
eases, and in the present instance they more than compensate for the com- 
paratively narrow field of the author's observation. 

The epidemic influenza of 1847-8 commenced in London about the 16th 
or 18th of November 1847; was most active from the 22d to the 30th of that 
month ) and ceased to be very prevalent by the 6th or 8th of December. 
During the remainder of that month, and the early months of 1848, however, 
it continued to prevail, and to impress its type upon sporadic diseases. 

The month of October 1847, was dry and very warm, its mean tempera- 
ture being 52.9°. Up to the 16th of November, the weather remained un- 
changed; when, in the course of four days, the thermometer fell 22.2°, and 
the earth was frozen. By the 22d, however, the mean temperature had risen 
to 44.7°, the barometer began to fall, fogs prevailed, a large quantity of rain 
fell, and the weather continued to be warm and wet until after the decline of 



1849.] Peacock on the Epidemic Catarrhal Fever of 1847-8. 149 

the influenza. On December 7th, or about the period when the ravages of 
the disease sensibly diminished, there was a remarkable fall of the barometer, 
which then stood at 28.381. 

The number of deaths attributed to influenza in the week ending Novem- 
ber 20th, and registered in the London Registry Office, were four; and in 
the succeeding weeks, up to January 1st, 1848, were, respectively, 36, 198, 
374, 270, 142, and 127. During the remaining winter months, and up to 
April 1st, the number progressively declined. In the four weeks preceding 
the latter date, the numbers were, respectively, 11, 10, 6, and 8. "The 
deaths registered as from influenza, amounted, for the entire six months (from 
October to April), to 1739. The Registrar-Greneral has, however, remarked 
that, during the six weeks the epidemic was at its height, not less than 5000 
persons died in excess of the average mortality of the period, an excess which 
throws itself in every class of disease ; the local maladies which had been the 
most predominant affections being, doubtless, in many cases, assigned as the 
cause of death." This excess was chiefly due to pulmonary affections, typhus, 
eruptive, and puerperal fevers. It is estimated that about one-fourth of the 
whole population of London was, more or less, affected by the influenza. The 
mortality of the epidemic was chiefly confined to persons who were in pre- 
viously unsound health, or of advanced age. The rate of mortality in child- 
hood was raised 83 per cent., in manhood 104 per cent., and in old age 247 
per cent. 

The epidemic, of which Dr. Peacock describes a part of the ravages in Lon- 
don, extended over a great part of Europe. It prevailed at Constantinople in 
August ; at Paris and G-eneva about the beginning of December ; at Madrid 
in January ; at Edinburgh at the same time as in London j while in some of 
the intermediate districts it was most felt during the last two weeks of De- 
cember. 

The great variety of symptoms presented by those who are attacked with 
influenza, has led to its division, by several authors, into numerous forms, 
such as inflammatory, bilious, rheumatismal, convulsive, simple, complicated, 
cephalic, abdominal, &c. Dr. Peacock admits three general varieties : 1st, 
simple catarrhal fever ; 2d, catarrhal fever, with pulmonary complication ; and 
3d, catarrhal fever, toith predominant disorder of the abdominal organs. The 
first two divisions comprise the cases of influenza generally recognized as such; 
and the third includes fever with bilious disorders, and of a remittent type, 
together with gastro-enteritic and bilious fever, complicated with rheumatism. 

Simple Catarrhal Fever. — The symptomatology of this form is accurately 
given by the author, but need not detain us, since most of our readers must 
be familiar with it. We may merely note his remark of the frequency of 
rheumatic affections, often of an intermittent type, towards the termination of 
the complaint. It is not easy, in many of these cases, particularly where the 
pain is limited to one side of the head, the orbit, &c, to determine whether 
the attack is rheumatismal or neuralgic. Often, however, it is clearly of the 
latter nature. Amongst children, a common complication noticed in the Lon- 
don epidemic was inflammation of the throat and larynx, and even membra- 
nous croup. The same remark is true of the influenza which prevailed in 
Philadelphia at the close of 1848. At that time cases of membranous croup 
were singularly frequent. 

Catarrhal Fever with Pulmonary Complication. — The most important pul- 
monary complication described by the author is capillary bronchitis, more 
generally known as suffocative catarrh. This affection occurred most fre- 
quently in persons who had been previously in bad health. One of its pecu- 
liar symptoms, and the cause producing it, are dwelt upon more fully than 



150 Reviews. [July 

by any other writer upon this subject; we allude to the increased resonance 
of the chest on percussion, which is observed in the advanced stage of the 
affection. On examining the bodies of those who perish from this form of 
disease, the lungs are found extremely inflated and emphysematous, and, 
instead of collapsing when the chest is laid open, they, in some cases, even 
protrude from the cavity. The emphysema is not confined to a portion, 
but affects the whole pulmonary tissue. This condition proceeds from the 
air being drawn into the pulmonary vesicles, and accumulated there by suc- 
cessive inspirations y for the expiratory act, which is much feebler than the 
inspiratory, is unable to force back the air which has been breathed, past the 
barrier of tenacious mucus, or fibrin, which clogs the lesser branches of the 
bronchia. The effect of pneumonic consolidation in perpetuating this emphy- 
sematous state of the lungs, is well shown and explained by the author. In 
some cases where the capillary bronchitis was complicated with pneumonia, 
and death took place from other causes some time after the acute attack, the 
smaller bronchial tubes were found dilated in those portions of the lung, 
chiefly, which had been hepatized. In these portions, doubtless, the paren- 
chymatous effusion had prevented the natural contractility of the bronchia 
from operating after the removal of the distending cause, and hence the dila- 
tation persisted. Dr. Peacock is of opinion that many cases of emphysema, 
dating from childhood, are to be explained by the occurrence, at this period of 
life, of an attack of capillary bronchitis which has been neglected, or which, 
from some other cause, has been sufficiently prolonged to render the dilatation 
of the pulmonary vesicles permanent. The great constancy of emphysema, 
as a result of capillary bronchitis, certainly favours this view. 

Pneumonia was not an ordinary complication of the epidemic described by 
Dr. Peacock. It was remarkable for the absence of pain in the greater num- 
ber of instances ; probably because it originated from within, and was not 
associated with pleurisy. In some cases there was decided jaundice, and in 
the others some yellowness of the conjunctiva. Notwithstanding the severity 
of the local affection, the serious complications in other organs, and the ex- 
treme prostration of the patient's strength, this disease proved fatal but in 
one of the seven cases met with by the author. On the other hand, he found 
capillary bronchitis invariably a most alarming, and, in five out of eleven 
cases, a fatal malady. 

The occurrence of influenza in phthisical patients was found to be extremely 
dangerous, not only from its immediate effects, but because it appeared to 
hasten the progress of the original disease. Several times, indeed, the author 
could trace the first symptoms of consumption to an attack of influenza. 

Epidemic Catarrhal Fever with Abdominal Complication. — The cases in- 
cluded under this head are divided, by Dr. Peacock, into, 1st, those charac- 
terized by disorder of the gastro-enteric mucous membrane; 2d, those in 
which the enteric affection was combined with various degrees of hepatic 
derangement, and a tendency either to relapse or to assume a remittent 
character; and, 3dly, those complicated with rheumatic symptoms. 

Under the first head, are described two forms of continued fever ; the one, 
ephemeral, with mild symptoms, and terminating in cure within from four to 
seven days ; the other, if we do not err, identical with typhoid fever (abdomi- 
nal typhus), for, in every point of its symptomatology, it closely resembles 
this affection. In the slowness of its invasion, for example, the dryness of 
the mouth, and sordes upon the teeth ; the restlessness, combined with torpor, 
followed by muttering or active delirium, and by coma; the meteorism, ten- 
derness, and gurgling of the abdomen; the diarrhoea and bloody stools ; slight 
bronchitis ; a duration of from twenty to thirty days ; with ulceration of the 



1849.] Peacock on the Epidemic Catarrhal Fever of 1847-8. 151 

glands of Peyer, swelling and softening of the mesenteric glands and spleen. 
In fact, the only characteristic symptom of typhoid fever which did not pre- 
sent itself, was the rose-coloured spots. 

The whole number of cases of " influenza with abdominal complication," 
recorded by the author, was thirty-one ; of which five were fatal, and of these 
latter, four belonged to the form of the disease under notice. They were all, 
however, aggravated by associated affections of a serious character. 

If, as we entertain no doubt, typhoid fever is a specific disease, which oc- 
curs in many parts of Europe and of the United States, with precisely the 
above cortege of symptoms, it is not easy to understand how it came to be 
regarded by Dr. Peacock as a form of influenza. There is, indeed, nothing 
in his description to show that this well-known and very regular disease under- 
went, in any considerable degree, the epidemic influence. It seems to have 
maintained the same characters, when observed by Dr. Peacock, as when it 
occurs either sporadically or epidemically, and unconnected in any manner 
with influenza. The author, in another place, assigns a reason for his arrange- 
ment ; we shall briefly examine it when speaking of the nature of influenza. 

The second form of abdominal complication in catarrhal fever, as described 
by Dr. Peacock, bears a close resemblance to our milder grades of remittent 
fever. The attack was usually sudden, with rigors, depression of strength, 
followed by hot skin, a full, frequent, and bounding pulse, thirst, loss of appe- 
tite, and bilious vomiting. At the end of a week or ten days, a rapid amend- 
ment took place, and the patient seemed convalescent ; but between the ele- 
venth and fourteenth days, sudden relapses occurred, with symptoms resembling 
those of the invasion, but speedily merging into a typhoid condition, with 
slow, feeble pulse, cool skin, jaundice, and pain or tenderness in the right 
hypochondrium. In three or four days more, the patient would begin to 
recover rapidly. Other cases, in which the invasion was more gradual, 
assumed a lower type. The mind was torpid, the matters vomited resembled 
coffee-grounds, and the region of the liver was acutely tender. Diarrhoea., 
bloody stools, and epistaxis were frequent. The febrile paroxysms were irre- 
gular, sometimes quotidian, sometimes tertian, or occurring at uncertain 
periods, and were always succeeded by extreme prostration and profuse per- 
spiration. 

These symptoms, it is well worthy of notice, are those which belong to a 
class of fevers never met with as independent maladies elsewhere than on the 
borders of marshes, or where similar atmospheric conditions exist, nor even 
then unless there is a wide daily f ange of the thermometer. Yet we find 
them, in the present case, arising, in a striking manner, in London, in the 
thickly peopled parts of which city true remittent fevers are, perhaps, never 
met with — and arising, too, after winter had fairly set in. It is difficult to 
refuse believing that the epidemic influence had power to create this unwonted 
morbid display, and to create it by a specific power independent of atmospheric 
and other external and habitual impressions. If it really possessed such a 
power, the solution of the problem of paludal diseases, which refers them to 
-vicissitudes of temperature, &c, is less simple than the advocates of this 
method suppose ; and the agency of miasmata may still be admitted as none 
the less real because it is mysterious. 

We are not informed of the proportionate number of cases of this form of 
the disease, and cannot, therefore, judge accurately of its relative fatality. It 
is, however, stated that, "notwithstanding the very threatening appearance of 
the cases of remittent fever, and the extreme prostration of strength following 
the relapses, every case terminated favourably ; and but one death occurred 



152 Reviews. [July 

from the low form of continued fever with hepatic disorder." In this case, 
permission to examine the body could not be obtained. 

The rheumatismal complication described by the author, is stated to have 
been associated with hepatic and enteric disorder, and low fever, with, in 
fact, the symptoms of typhoid or remittent fever, but in such a manner that 
pain was a predominant feature. It was generally of a remittent or intermit- 
tent character, was most distressing in the forehead, and, in some cases, was 
limited to one temple, or to one eyebrow or eyeball. The breath had a pecu- 
liarly unpleasant acid and fetid odour. After the paroxysms, there was ex- 
treme collapse, with profuse perspiration, and cold and livid extremities. This 
description does not, we think, clearly indicate the rheumatic nature of the 
pain in question. Without denying that it possessed this character, the ques- 
tion may fairly be asked — was it not neuralgic ? The treatment which suc- 
cessfully combated this distressing form of the disease at first sight, appears to 
favour the author's opinion ; but, as we shall endeavour to show further on, 
does not fully establish it. 

Treatment. — The simple catarrhal variety of influenza was successfully 
treated by Dr. Peacock with an emetic, followed by a full dose of opium, or 
of an opiate combined with a diaphoretic, such as Dover's powder and nitre. 

The author confirms, by his experience, the inutility of general depletion 
where influenza is complicated with capillary bronchitis. Dry, or scarified 
cups, applied between the shoulders, he found more beneficial, but by no means 
uniformly useful. He recommends the employment of antimonials in emetic 
doses, at the commencement of the disease, and their continuation as nause- 
ants through the active stages. He reminds the reader, however, that the 
efficacy of emetics decreases with each repetition of them. After emesis and 
cupping, opiates should be administered in quantities proportioned to the ex- 
citement and restlessness of the patient, and combined with small doses of 
mercury, so as slightly to affect the patient's gums. While this treatment 
is in progress, it is desirable that counter-irritation should also be employed, 
and a blister placed between the shoulders. 

u In the second stage of the disease, when crepitation is extensively audi- 
ble over different parts of the lungs, the prospect of recovery becomes small, 
and the available means are necessarily very limited." Emetics of ipecacu- 
anha and sulphate of zinc may be employed, to aid in expelling the viscid 
secretion of the bronchia ; but stimulants and anodynes must be chiefly de- 
pended upon. Of these, ether, squills, senega, and serpentaria, with camphor 
and the several narcotics, may be prescribed, and the strength supported with 
animal broths, jellies, wine, and brandy. We are disposed to think that the 
author does not give sufficient prominence to the medicinal effects of brandy. 
There are certainly cases in which it almost alone will be found effectual in 
promoting expectoration, and sustaining nature until the morbid cause of the 
pulmonary secretion has spent its force. Dr. Peacock well remarks that 
stimulants are of little avail where the depression of strength is, from the first, 
such as to forbid depletion and sedative measures generally. During conva- 
lescence from the form of influenza under notice, tonics, and especially qui- 
nine, were given with advantage ; and where the sputa continued to be viscid, 
expectorants and anodynes, with alkalies. The difficulty of breathing, which 
is so apt to recur upon slight exposure, was generally much relieved by the 
tincture of lobelia alone, or in combination with anodynes, and in such doses 
as to produce slight nausea. 

In the author's treatment of influenza complicated with continued typhoid 
fever, the only points of interest are the liberal employment of tonics and 
stimulants during the stages of prostration, and of anodynes to relieve sleep- 



1849.] Peacock on the Epidemic Catarrhal Fever of 1847-8. 153 

lessness in the decline of the attack. The remittent form he treated with qui- 
nine, in doses of two or three grains, three or four times daily. As the 
paroxysms became more clearly intermittent, the dose of this medicine was 
augmented twofold. Ammonia and brandy were likewise prescribed freely. 
The profuse perspirations were counteracted with the mineral acids and bark. 

In the "rheumatic" form, with " distressing pains in the head, chiefly ex- 
perienced or aggravated at night, with great restlessness or inability to sleep, 
and nocturnal or continuous delirium, the most rapid and decided amendment 
followed the exhibition of colchicum," of which the tincture of the seeds was 
given every three, four, or six hours, in doses of not more than four or five 
minims. We before suggested that the pain experienced in this form might 
be neuralgic rather than rheumatismal, and the account given of the treatment 
which was successful in relieving it, corroborates this view. For it is contrary 
to general experience, that so small a dose of colchicum should produce the 
results ascribed to it ; and, in fact, we are told that "it was almost invariably 
combined with ammonia and opium j stimulants or tonics, such as wine or 
brandy, bark or quinine, being usually administered at the time, or later in 
the attack." Neuralgic pains, occurring in miasmatic diseases, are usually 
found amenable to such treatment, but would scarcely yield, we suspect, to 
five minim doses of a medicine whose average dose is from f 3ss to f 3j. 

The Nature and Causes of the Epidemic. — As introductory to the discussion 
of this subject, Dr. Peacock endeavours to establish the proposition, already 
adverted to, that the several forms of the disease, which are described by him, 
proceeded from the direct agency of the epidemic influence, and are, therefore, 
in reality what he regards them to be, varieties of one and the same malady. 

After showing that, according to the London bills of mortality, the increase 
of deaths during the epidemic was "scarcely greater from pulmonary diseases 
than from typhus, remittent fever, erysipelas, rheumatism," &c, and that a 
similar fact had been recorded of epidemics of influenza in many different 
places, he sums up the argument as follows : — 

" When we consider the remarkable coincidence in the period of accession, 
general prevalence, and decline, of the several forms of pulmonary, enteric, 
hepatic, and rheumatic affections ; the remittent and typhoid character of the 
febrile diseases ; the very common occurrence of symptoms referable to the 
stomach, intestines, and liver, in the cases with predominant affection of the 
lungs, and of those of bronchitis, and pneumonia in the abdominal form of the 
disease ; and when we further find that these symptoms were features not 
peculiar to the recent influenza alone, but have also, in a greater or less de- 
gree, characterized all its former appearances in this or other countries ) we 
can scarcely refrain from acknowledging, that these several affections are not 
merely coetaneous, but correlative, and types and modifications of one disease, 
with which they have a common origin." 

To this conclusion we are, by no means, prepared to subscribe. It is not a 
necessary consequence of the premises which the author so fairly and so fully 
states. The argument proves too much; for if unity of nature is admitted 
for the several forms above described, for the epidemic simple catarrh and the 
continued typhoid fever, for example, upon the ground of their frequent coin- 
cidence, then we are bound to acknowledge a like unity of nature between 
either or all of these forms, and small-pox, scarlatina, measles, puerperal fever, 
whooping-cough, &c, from all of which there was a great increase in the num- 
ber of deaths during the period of the influenza. Such a train of reasoning, 
carried a little further, would soon issue in re-establishing the obsolete dogma 
of the unity of disease, a doctrine which has done infinite mischief in effacing 
from the minds of medical reasoners those ideas of difference among diseases, 



154 Reviews. [July 

without which it is impossible to observe their phenomena truly, to describe 
them intelligibly, or to treat them rationally. 

It is, indeed, a property of several epidemic maladies to be attended with 
an unusual development of ordinary sporadic affections, which are, in that 
case, more or less impressed with the epidemic type; but to attribute identity 
of nature to both classes, on account of such coincidence, would be to commit 
the fallacy of ascribing to an accidental the virtue of an essential cause, to 
assume that all effects whatever of a given cause must be identical in their 
nature. Even among cognizable causes, many produce very various effects, 
according to the intensity of action of the cause, or the intermediate links 
between it and the particular effect which we witness. Mere difference of 
intensity of force will give rise to direct results of essentially the same nature, 
but the interposition of a new cause, of another sort, will give rise to indirect 
results, which may partake, in a very slight degree, of the nature of the 
original cause. 

So in the case before us ; the power whose appropriate and direct effect is 
to produce epidemic catarrh, may indirectly develop typhoid fever and small- 
pox, without the latter possessing a common nature with the former ; it may 
develop them simply by removing the obstacles which exist to their ordinary 
prevalence. If, for instance, prostration of the nervous system is favourable 
to the development of typhus, erysipelas, &c, and the essential cause of influ- 
enza prostrates the nervous system, then a condition exists which is adapted 
to promote the occurrence of these diseases. Something of this sort we are 
disposed to regard as the real connection between influenza and the maladies 
which prevail in company with it, and which receive, more or less distinctly, 
its impress. We can perceive no reason for believing, with the author, that 
both are, in their nature, u correlative/' or mutually dependent upon one an- 
other for existence; but there is certainly substantial ground for believing 
that the former promotes the unwonted development of the latter by its de- 
bilitating, and, perhaps, poisonous influence upon the economy. 

With respect to the mode of action and the nature of the morbific influence, 
the author does not offer any suggestions that have not already been proposed 
by other writers. He believes that the phenomena of the disease point to the 
nervous system and the blood, as the portions of the organism first involved. 
He does not allude to the ingenious supposition that the poison is material ; 
a view inferred from the disease so generally attacking the mucous membrane 
of the pharynx and air-passages, and proceeding from above downwards, and 
which has, to some extent, been confirmed by the discovery of a new ingre- 
dient in the atmosphere (ozone) during the prevalence of influenza and other 
epidemics. Facts have been mentioned by several writers, which seem to 
prove that influenza may be propagated by contagion. To these, Dr. Peacock 
adds the following : — " I cannot but regard it as worthy of remark, that, while 
four persons, two nurses and two patients, took the disease in the wards of 
the hospital during the recent epidemic, and had severe attacks, these cases 
all occurred in two wards in which many influenza patients were under treat- 
ment j while in a third ward, into which no case was admitted, both nurses 
and patients escaped the disease altogether, or had it so slightly as not to 
require any medical attendance." 

The concluding third of the volume before us is filled with twenty illustra- 
tive cases, which present examples of the several forms of influenza before 
described. These records are well drawn up, and fully confirm the impression 
made by the previous portion of the essay, that the author is a sound and 
practised observer. He has produced a work which deserves to rank with the 
best in the department of medical literature to which it belongs. A. S. 



1849.] 155 



BIBLIOGRAPHICAL NOTICES. 



Art. XIX. — Practical Pharmacy. The Arrangements, Apparatus, and Manipu- 
lations of the Pharmaceutical Shop and Laboratory. By Francis Mohr, Ph. 
D., and Theophilus Redwood : edited, with extensive additions, by Wm. Proc- 
ter, Jr. Illustrated by 500 engravings on wood. Philadelphia: Lea and 
Blanchard, 1849. 

The publishers of this work have conferred a favour on the profession by 
their successful endeavours to produce it to the American public in a form cre- 
ditable to themselves and equal to the value and importance of the subject. 
Pharmacy, in its practical operations, had been much neglected as a part of the 
education of the apothecary of the United States, until, within a few years, 
it was introduced as a prominent portion of the public instruction afforded by 
the College of Pharmacy of this city. Previously, all the knowledge obtained 
by the apprentice was confined to that afforded by the limited scope of his own 
immediate circle, consisting chiefly of a routine of operations, the perfection or 
imperfection of which was dependent on the source from which they were de- 
rived. It was hence no uncommon occurrence to meet with some preparations 
which were very inactive when procured from any particular shop, while the 
same place furnished others of undoubted efficacy. Viewing it as a matter of 
great importance to afford every facility to the apothecary to acquire perfection 
in his art, the College of Pharmacy resolved to enlarge their sphere of useful- 
ness by establishing a chair of practical pharmacy, and the able editor of the 
work before us was chosen to fill this station. In the publication, he appears 
as editor of the American edition ; but from the very extensive and valuable 
additions, both as to topics discussed and to extension of those already con- 
tained in the original work, he may rather be considered in the light of one of 
the authors. In thus extending the work, subjects are noticed which had es- 
caped the attention of the original authors, and the whole is better adapted to 
the wants and requisitions of American pharmacy. 

The authors of the original work, Francis Mohr, teacher of Pharmacy in the 
Royal Prussian College of Medicine, Coblentz, and Theophilus Redwood, Prof. 
of Chemistry and Pharmacy in the Pharmaceutical Society of Great Britain, 
are well known for their contributions to the improvements of pharmaceutical 
knowledge, and a work from their pens must be considered as an exponent of 
the condition of pharmacy as it exists abroad ; and when, in addition, we have 
whatever may be peculiar to American pharmacy, we are provided with all the 
requisites by which to form a skillful and scientific pharmaceutist. 

The plan of the work is modified from the original, by breaking the matter 
into chapters, which is very obviously an advantage in a book of reference, in 
enabling the eye to distinguish at a glance the particular part sought ; and, by 
a kind of classification, leading to information which may not be specifically 
noticed, but which would be appropriately sought for under its particular head. 

The arrangements of the shop are necessarily first noticed, together with the 
apartments which are required for storage and operations, which could not be 
advantageously conducted, mixed with the more immediate and important du- 
ties of dispensing medicines. Under this head are considered the importance 
of location ; the form and adaptation of the shop itself; the means of heating 
with such applications to other purposes as the methods will afford ; the means 
of ventilation, as best adapted to health and comfort ; the methods of lighting 
and their incidental advantages ; together with various minutiae of arrange- 
ments calculated to facilitate the operations and economize the time, and there- 
by prevent confusion and delay. 



156 Bibliographical Notices. [July 

The operation of weighing and measuring, together with the requisite infor- 
mation concerning the various standards adopted by different countries and 
pharmacopoeias, is fully discussed, and sources of error and of injury to instru- 
ments to be avoided, pointed out, — illustrated by woodcuts of the forms best 
adapted for practice, and of modes of operating which are most convenient. 
Under this head, relative weight or specific gravity, as a distinctive character 
of many substances, is explained and illustrated in an ample manner. 

The sources of heat, the modes of application, and the instruments used, 
with their applications, occupy the two succeeding chapters ; including an ex- 
tensive range, from which selections may be advantageously made, and which 
may be most usefully applied by any individual to the local peculiarities of his 
situation ; their adaptation to his peculiar wants, or the facilities for procuring, 
or economy in using, any particular form of fuel. 

Comminution under all its forms occupies another chapter. In this place is 
noticed a mill of American origin (Swift's drug mill), very simple in construc- 
tion, and obviously well adapted to most of these operations. 

Decantation, washing, separation of fluids, filtration, clarification, decolora- 
tion, and expression, operations very simple in their character, but requiring 
care and a peculiar kind of information for their successful performance, occupy 
a due share of notice and illustration, and various forms of apparatus and modes 
of manipulation are presented, and their adaptation to the circumstances pointed 
out. 

In chapter ninth is contained a very full and complete examination of the 
subject of solution, and the purposes to which this process is applied. The 
different methods and apparatus applicable to obtain all the portions of any 
body soluble in the various menstrua employed, are amply illustrated, and the 
applications to which each may be peculiarly adapted, together with the cau- 
tions necessary to be attended to in their use, are given in a clear and perspi- 
cuous style. The process of percolation, or displacement, necessarily occupies 
a very considerable share of notice, as it is a method of manipulation calculated 
to produce most excellent results when well performed, and with the proper 
precautions in the condition of the matters acted on, and in the whole being 
subjected to the complete and successive action of the solvents ; while, on the 
other hand, very imperfect results are necessarily the consequence of any inat- 
tention to the minutiae ; by partial action, the effect of imperfect comminution, 
loose packing, peculiarity in the material itself, the establishment of currents, 
&c. The remarks under this head deserve the careful and studious attention 
of every one who should attempt this process ; not only from regard to economy, 
in obtaining from the matter operated on all its soluble portions, but also to 
avoid deception as to the activity of fluid medicaments (syrups, tinctures, &c), 
obtained in this way ; it being naturally presumed that, when this method has 
been used, full strength and activity are insured in consequence of the perfection 
of the action when properly conducted. Other results also will naturally flow 
from the same source ; one of which — a distrust in the process itself, arising 
from doubt of the perfection of action, or of its capability of application except 
in the most experienced hands — would, if common, cause its almost entire 
abandonment, and the substitution of processes manifestly inferior. Among 
the illustrations, will be found several extemporaneous forms well adapted for 
small quantities, and also for domestic use ; in which articles readily obtain- 
able may easily be converted into displacement filters, and by which the family 
of the patient may, with a few instructions, obtain infusions superior to those 
ordinarily made under similar circumstances. 

In the succeeding chapters are considered evaporation, including the prepa- 
ration of extracts, and the operation of drying, distillation, sublimation, and 
the various operations in which heat is necessary, calcination, reduction, &c. ; 
generation and absorption of gases : all copiously illustrated by the most ap- 
proved forms of apparatus. 

Chapter fourteen is on subjects important in a pharmaceutical point of view, 
but entirely omitted in the original work, viz., general remarks on the prepa- 
ration of articles for external application. The remainder of the work is 
chiefly concerned in miscellaneous operations, many of which are of frequent 



1849.] Quain's Human Anatomy. 157 

or every day occurrence to the pharmaceutist ; while others, he is called upon 
only occasionally to perform, but in which he is nevertheless expected to exhibit 
a proper degree of skill. Some of the operations noticed are laborious in their 
nature, and any appliances calculated to ameliorate this condition would be 
received with a just reward of gratitude; and we may here point out an in- 
stance in which this is fully earned, by requesting the reader to turn to the 
apparatus figured in page 524, which seems admirably calculated to relieve the 
pharmaceutist from a heavy labour, in preparing one very common form of 
external application. 

In conclusion, we may add that there is appended to the American edition, a 
description of convenient apparatus for testing, — a list of the different reagents, 
and the mode of ascertaining their purity, together with the means ot purifying 
and preparing such as may not readily be Obtained, with sufficient freedom from 
contamination for the purposes to which they are to be applied. It must be 
evident, from the views of the work which we have thus given, although ex- 
tremely meagre in proportion to the subjects embraced, that it has accomplished 
a long-desired object, in filling up a void in pharmaceutical education, and that 
every pharmaceutist will consider it as an important addition to his library, 
and a valuable source of reference obtainable at comparatively small cost. 

R. B, 



Art. XX. — Human Anatomy. By Jonas Quain, M. D. Edited by Richard 
Quain, M. D., and William Sharpey, M. D., F. R. S., Professors of Anatomy 
and Physiology, in University College, London. First American, from the 
fifth London edition. Edited by Joseph Leidy, M. D. In two volumes, with 
over 500 illustrations. Philadelphia: Lea & Blanchard, 1849. 

An accurate acquaintance with the healthy structure of the body must pre- 
cede all successful physiological and pathological study. And this is becoming 
more and more an established truth, in proportion to the increasing minuteness 
of anatomical investigations, — each functional expression, whether of a morbid 
or of a healthy character, being, in all probability, associated with, and depend- 
ent on, its own peculiar structural condition. 

It is gratifying, therefore, to see that this important branch of medical sci- 
ence is being so successfully cultivated. With constantly improving means for 
investigation, anatomists are pursuing nature into her most retired haunts ; and 
if they cannot ascertain hoiv she accomplishes her work, they seem determined.; 
at least, to detect the instruments which she employs, and the conditions under 
which she operates. Nor are their labours confined to human anatomy; plants, 
and all the tribes of animated nature, and even the inorganic world, are made 
to contribute largely to improve man's knowledge of his own " curiously and 
wonderfully-made" frame. Youthful students of medicine are prone to cavil 
at, what they consider, this useless display of research on the part of com- 
parative anatomists ; but a little more reflection will convince them of their 
error, and will show them how easy is the transition, the progressive march, 
from the lowest order of created beings to the highest; — how, for example, 
the knowledge of the mode in which the circulation and nutrition of the 
plant is effected, has influenced our ideas concerning these processes in the 
human individual. Anatomy is thus rendered the most entertaining of the 
associated departments of medicine, instead of the dull, dry thing it has so 
often been made by those who cultivate and teach it; as though it were an iso- 
lated branch of study, abounding in hard names which mean nothing, a chaos 
of formless objects having very little relationship with each other, and very lit- 
tle bearing upon the practical duties and knowledge of the physician. 

There have been many very excellent treatises on Anatomy published re- 
cently, both in the English and foreign languages. Some of these have been 
presented to the American student to guide and assist him in his labours. Of 
No. XXXV.— July, 1849. 11 



158 Bibliographical Notices. [July 

these, the work, of which the title prefaces this article, is the latest, and we 
propose to call the attention of our readers to its character and value. 

Its authors and editors are well known to the profession wherever the kindred 
studies of Anatomy and Physiology are cultivated. The Messrs. Quain have 
enriched our science with excellent general and special treatises on Anatomy ; 
and the most valuable collection of information in Anatomy and Physiology, 
which our language contains (The Cyclopaedia of Anatomy and Physiology), 
has been largely indebted to Dr. Sharpey for his contributions. Concerning 
the American editor, we need only say that, those who know him, build high 
expectations and confidence upon his untiring zeal and industry in the pro- 
secution of his favourite pursuits, and upon the skill with which he conducts 
them ; those who do not know him, we would refer to the pages of this Journal, 
and the Journal of the Academy of Natural Sciences, of this city, for the proofs 
of his ability to fulfil with honour and usefulness the task of editing the work 
before us. 

The treatise is commenced with a very interesting and able Introduction to 
General Anatomy, from the pen of Dr. Sharpey. The author gives an account 
of the physical, chemical, and vital properties of the textures with great clear- 
ness, and with sufficient detail to render the description of real and valuable 
assistance to the reader. That portion of this chapter which is devoted to the 
vital peculiarities of the tissues is particularly full and attractive ; and, while 
the writer constantly feels the necessity of receiving with caution the extraor- • 
dinary revelations of the microscope, he is not thereby rendered incredulous, 
but presents a well arranged and carefully digested view of the present state of 
knowledge respecting the development and formation of the textures. The sub- 
joined extract will show the good judgment which Dr. Sharpey displays in the 
appreciation of recent discoveries, and his views respecting their importance. 
(See p. 51.) 

" No branch of knowledge can be said to be'complete ; but there is, perhaps, 
none which can, at the present moment, be more emphatically pronounced to 
be in a state of progress than that which relates to the origin and development 
of the textures ; much of the current opinion on the subject is uncertain, and 
must be received with caution. In these circumstances, in order both to facili- 
tate the exposition, and to explain to the reader more fully the groundwork of 
the doctrines in question, we shall begin with a short account of the develop- 
ment of the tissues of vegetables ; for it was in consequence of the discoveries 
made in the vegetable kingdom that the happy idea arose of applying the prin- 
ciple of cellular development to explain the formation of animal structures, and 
they still afford important aid in the study of that, as yet, more obscure process." 
Then follows an "Outline of the Formation of Vegetable Structure," from cells 
which in the progress of their development increase in size, become modified 
in shape from circumstances to which they are exposed in the plant itself, and 
coalesce with, and open into, adjoining cells, thus forming tubes. The con- 
tents, too, of these cells suffer changes of chemical constitution, and physical 
form and arrangement, whereby new matters are generated, and the structure 
of the vegetable fabric is built up. Turning, now, to the consideration of the 
formation of the animal textures, the writer points out the analogy which exists 
between the process of development as it occurs in these and that which takes 
place in vegetables ; and then proceeds with the subject when this resemblance 
has ceased to be so striking, from the greater complexity of the structure of 
animal textures. Some remarks on the nutrition and regeneration of the tis- 
sues close this chapter. The writer makes no attempt at novelty of fact or of 
illustration ; but his views are expressed with very great clearness, and excel- 
lent judgment is displayed in sifting and arranging the great mass of testimony, 
which is often of a conflicting character, so that as near an approach may be 
made to truth as circumstances will permit: the text is fully illustrated by nu- 
merous well-executed drawings. That this minuteness of study devoted to micro- 
scopic investigations is really of a valuable practical nature, the following pas- 
sage shows: — (p. 71.) 

" In concluding what it has been deemed advisable to state in the foregoing 



1849.] Quain's Human Anatomy. 159 

pages respecting the development of the textures, we may remark, that, besides 
what is due to its intrinsic importance, the study of this subject derives great 
additional interest from the aid it promises to ajfford in its application to patho- 
logical inquiries. Researches which have been made within the last few years, 
and which are still zealously carried on, tend to show that the structures which 
constitute morbid growths, are formed by a process analogous to that by which 
the natural or sound tissues are developed: some of these morbid productions, 
indeed, are in no way to be distinguished from cellular, fibrous, cartilaginous, 
and other natural structures, and have, doubtless, a similar mode of origin ; 
others, again, so far as yet appears, are peculiar in structure and composition, 
but still their production is with much probability to be referred to the same 
general process." 

Osteology constitutes the first division of the treatise. As here discussed, it 
comprises a very full history and description of the " osseous tissue," its com- 
position and internal structure, and the mode of its formation and growth : — 
with the special anatomy of each division, and of each individual bone of the 
skeleton. We are sure that the reader will feel well repaid by the perusal of 
the chapters which are devoted to this portion of the anatomy, comprising more 
than one hundred and fifty pages. He will find the descriptions of the bones 
clear and amply detailed, the anomalies of each mentioned, and specifications 
of their individual history, as to their period of ossification and development — 
the latter being a peculiarity of this work among all the systematic treatises on 
anatomy in the English language. (See the American Editor's preface.) We 
have nowhere seen a more interesting and more lucid explanation of the inti- 
mate structure of bone, — the wise provision made for the circulation of blood 
through its dense tissue, and the circumstances and conditions which attend its 
development and progressive growth. Indeed, this book must be regarded as 
the fountain head of our knowledge regarding this latter point: for to Dr. 
Sharpey, more than to any other, is due the merit of having successfully studied 
the " intra-membranous" mode of ossification. 

There are some points still in doubt in the history of the osseous tissue. Thus 
with regard to the mode of production of the lacunae, or the corpuscles of Pur- 
kinj6, as they have been termed, differences of opinion exist as to whether these 
little feeders, as it were, of the minute vascular canals of the compact structure, 
are produced from the original cartilage cells, by some change of action ; or 
from the nucleus of these cells ; or whether they are not little vacuities left in 
the ossifying mass by the unequal deposition of the bony matter. Dr. Leidy 
records observations at page 91, which inclines him to adopt the first view, that 
of Schwann. The observations were made upon the os frontis of a human 
embryo, measuring two inches from heel to vertex, the meshes of the osseous 
rete filled with cartilage cells contained in a transparent matrix or hyaline sub- 
stance. He says, "Upon examining the border of the bone, I noticed a system 
of reticulated osseous fibres, proceeding from the primitive ossific rete into the 
intercellular substance of the cartilage cells, apparently by a deposit of earthy 
salts, in a linear direction. In such positions, I observed that the cartilage- 
cells had already protruded, or had connected with them the canaliculi ; and 
these appear at this time only, because several cells which I noticed at the edge 
of the primitive bony rete, partly enveloped in the osseous deposit, had the cana- 
liculi passing into the latter, while on the unossified or cartilaginous side, none 
had as yet been developed. The cell wall has until now apparently remained 
unchanged, but commences to blend or fuse itself with the intercellular sub- 
stance, and with the secondary osseous fibrillse. The Purkinjean corpuscles, 
which are perfectly formed in the osseous structure at this time, have the same 
diameter, or nearly so, as the cartilage corpuscle from which they originated, 
and they still contain a granular nucleus, readily brought into view by iodine, 
which corresponds to that of the cartilage corpuscle, and has about the same 
measurement. At a later period the nucleus of the Purkinjean corpuscle ap- 
pears to dissolve away." 

With reference to the mode in which the bones increase in length, the au- 
thors incline to the opinion that it is not by interstitial deposit. This has 
always seemed strange to us, and anomalous; since, in other organs, an inter- 



160 Bibliographical Notices. [July 

stitial growth is manifest. And, as Dr. Morton remarks, in his recent treatise 
on anatomy, p. 29, "the fact of such an interstitial deposit in bones is deduci- 
ble from the circumstance, that the inequalities of a long bone are removed 
further from its centre as the shaft elongates. Thus, the trochanter minor of 
the os femoris, although it is below the terminal epiphysis, constantly removes 
from the centre of the shaft of the bone, until this has ceased to lengthen. 

Our space will not admit of any further notice of this portion of the work be- 
fore us. We can merely enumerate a few additional items of interest, which 
have particularly attracted us in reading its pages : such as the description of 
the intermaxillary bone of the human embryo, — a portion of the superior max- 
illary, which had not been observed as a normal condition of the human bone 
until it was recently discovered by Dr. Leidy (see p. 143) ; the analogy drawn 
between the cranial bones and the vertebras ; the description of the pelvis. 

We proceed to notice the chapters on Myology, — passing over those which 
describe the areolar, fibrous, elastic, and cartilage tissues, the synovial mem- 
branes, the articulations, and the fasciae ; although they are all written with 
great care, and embody all that is known that is interesting and instructive, 
concerning the anatomy of these structures. 

In treating of Myology, the same course is pursued as with the other tissues : 
the general anatomy and histology of the tissue is first given, and then follows 
the description of the individual muscles, with the best method of dissecting 
each particular region of the body for the display of its motor apparatus. The 
situation and relations of the muscles are well detailed, and their actions fully 
explained ; and anomalies of situation and condition are noted, when any such 
exist. Both divisions of the subject are illustrated' by numerous drawings ; but 
those connected with the special anatomy of the muscular system, though cor- 
rect, are almost all too small, it appears to us, to afford much assistance to the 
student ; however, this very circumstance, may, happily, have the effect of in- 
ducing him to seek better illustrations in the dissecting-room. 

All the points of interest belonging to the general anatomy of the muscular 
tissue are explained as fully as the state of positive knowledge on this subject 
will permit. Certainly, no systematic treatise on anatomy in our language 
combines more amplitude of detail and accuracy of statement concerning these 
subjects than the one before us : the results of the investigations of Mr. Bowman, 
Wilson, Dr. Sharpey, and the numerous continental anatomists, are here all 
newly arranged and set before the student. We are pleased to see several new 
observations and inferences of Dr. Leidy interspersed with those of the others. 
Thus, in speaking of that "vexata quaestio/' the mode of connection between 
the extremities of the muscular fibres and the tendinous tissue, he says, " The 
filaments of areolar tissue, which form the sheaths of the muscular fasciculi, for 
the most part wind diagonally around the latter, occasionally passing in between 
the fibres, and intermingling with some fine filaments of elastic tissue which 
are found in this situation. The sheaths are also connected together by fila- 
ments from them, having the same diagonally crossing course. 

" At the extremity of the muscular fasciculi, the filaments of the areolar sheaths 
become more or less straight, and combine with the fibrous filaments originating 
in this position, to form the tendinous connection of the muscle." P. 319. 

This explanation, besides being very ingenious, shows the wise economy by 
which the same tissue is made, by a slight modification of disposition, to assume 
two different and opposite properties: each fibre, or bundle of fibres, of the 
areolar tissue when straight is inelastic ; but it is rendered virtually elastic, and 
is thus adapted to the varying length of the muscle in which it is placed, by 
being disposed in a special manner around the latter, as we would arrange a 
piece of wire to make the coil springy : on the other hand, when an unyielding 
cord is required, upon which the muscle may exert its contractile power, the 
fibres of the areolar tissue which pervade the muscle are collected into a straight 
bundle, and thus constitute the tendon. We see other valuable annotations 
from the same pen, touching the reality of the division of the muscular fibre 
into component fibrillae, and transverse disks ; the persistence of the nuclei in 
the sarcous substance, &c. 
This part of the work is concluded by copious tables, in which the muscles 



1849.] Quain's Human Anatomy. 161 

are grouped together in the order of their position in dissection, and also accord- 
ing to their actions. 

Angeiology is the subject next considered, embracing the organs of the circu- 
lation, together with the associated system of lymphatic and absorbent vessels. 
Nearly two hundred pages of the work are devoted to the description of this 
important part of anatomy. 

The account of the circulatory apparatus is taken chiefly from the special 
treatise on this subject by Mr. Quain. It comprises dissertations on the deve- 
lopment and structure of the heart, its weight and dimensions, and its action, 
both in the foetus and in the individual after birth ; an interesting chapter on 
the blood ; the general anatomy of the arteries, veins, and capillaries, and the 
special and surgical anatomy of the two former in full detail. One of the great 
excellences of this portion of the book consists in the care with which the 
anomalies in the course and distribution of the chief vessels are described, and 
the relations which they bear to the neighbouring structures : the surgeon will 
find here an admirable work for reference. We have only to regret that the 
drawings are so small. 

Next in order are several chapters devoted to the description of the epidermic 
and epithelial tissues, the pigment cells, the adipose tissue, the serous and 
mucous membranes, the skin, and its complicated apparatus of associated struc- 
tures, and a general account of the secreting glands. 

The description given of the organs of respiration will be found to be exceed- 
ingly complete and interesting, as regards their general and intimate structure 
and development. We shall notice only one point. It has generally been sup- 
posed and taught, that the lobules of the lungs did not communicate with each 
other, but that the air-cells of the individual lobules admitted of a free inter- 
passage of air by means of lateral openings ; and injected and corroded speci- 
mens of the lungs have been exhibited, as substantiating this opinion. It 
seems, however, that, from recent careful examinations made by Rainey, Ros- 
signol and others, this idea is incorrect — that no such intercommunication 
exists between the cells of the separate lobules. "The cells themselves appear 
like polyhedral alveolar cavities, separated from each other by thin and rather 
shallow intervening septa, and of course opening into the air-passages. They 
do not open into one another by anastomosis or lateral communication, but 
freely communicate through the medium of the common air-passage to which 
they belong." P. 118, vol. ii. And with reference to this, Dr. Leidy adds a 
note, accompanied by a very satisfactory drawing, showing that "there are 
two sources of error which may lead to the opinion that the air-cells of the 
lungs directly and freely intercommunicate : one is, the liability of confounding 
intercellular areolar tissue, when inflated, with the air-cells themselves ; the 
other, the danger of mistaking the bronchioles for air-cells." P. 107, vol. ii. 
The drawings connected with this portion of the work are very beautiful, and 
are really illustrations of the textual descriptions. 

In the department of Neurology, we venture to think that the present treatise 
is superior to any similar work in the English language. The account which 
it embraces of the nervous system, although exceedingly voluminous, may be 
read with positive pleasure. Very diiferent is it, in this respect, from most 
other systems of anatomy, which, by their confused descriptions, and formida- 
ble array of names without intelligible meanings, have rendered this the most 
wearisome and unsatisfactory department of anatomical study. 

The minute investigation of the nervous substance as regards its intimate 
structure, is more difficult and laborious probably than that of any other tissue, 
chiefly perhaps on account of its extreme delicacy ; hence the many conflicting 
statements concerning it. 

Our restricted limits will scarcely allow us to do more than call the attention 
of our readers to some of the sections on the nervous system, as here elaborated, 
which will, we think, be found particularly interesting. We would specify the 
author's account of the origin and terminations of the nerves, concerning which 
much discrepancy of statement exists ; the pages devoted to the consideration 
of the cerebro-spinal axis, and the important tables respecting the weight of 
the encephalon and its different parts, absolutely, and as compared with the 



162 Bibliographical Notices. [July 

rest of the body, in the two sexes, and at different ages ; the description of the 
internal structure of the brain, and medulla oblongata ; and to the descriptive 
anatomy of the uterine nerves, concerning which it will be seen that the author 
does not concur with Dr. Lee in his opinions regarding the nerves of the gravid 
uterus. He says, at p. 356, vol. ii., "The recent dissections of M. Beck (if, as 
they seem to be, accurate), prove that the nerves do not alter in their thickness 
during pregnancy ; at least, that no alteration occurs before they enter the tissue 
of the uterus ; while that organ itself, and the vessels which supply it, undergo 
a remarkable augmentation in size." — " The representations of the gravid uterus 
and of the unimpregnated uterus of a person who had borne children, which 
are contained in his paper, show the nervous fibrils to be of the same size in 
both cases; and the author (it is stated in a note, p. 222,) has ascertained, by 
another dissection, that no difference in thickness is perceptible between the 
nerves of the virgin uterus and those just alluded to." 

The organs of the senses are next described, with considerable minuteness of 
detail. The precise mode in which the nerves of special sense terminate, is con- 
sidered by the authors to be still a matter of doubt. 

One hundred pages are devoted to the digestive organs. This section contains 
an exceedingly complete history of the teeth, comprising the results of the 
labours of the many distinguished anatomists who have recently made this 
their study, and well illustrated by good drawings ; a description of the struc- 
ture of the tongue and salivary glands ; a full survey of the whole alimentary 
canal, its intimate structure and development ; and an enlarged account of the 
important glandular and other organs of the abdomen concerned in digestion. 
This part of the work displays a great deal of research, both original, and 
among the writings which are most authoritative on the subjects treated of, 
many of which are not accessible to students and practitioners in this country. 
The ordinary physical appearances of the organs are very clearly pointed out, 
— a matter of much importance to those who wish to study the post-mortem 
phases of disease, since it furnishes them with an excellent standard of the 
healthy condition of the structures. 

In the description of the liver, the opinions of Mr. Kiernan, which have 
been very widely made known, are looked upon as the most correct, and the 
most explanatory of the various morbid conditions to which this organ is prone. 
The researches of other more recent anatomists, however, are recorded, when- 
ever they substantiate or conflict with the statements of the English investi- 
gator ; so that a very fair view of the state of our knowledge concerning the 
liver is here presented. The American editor has also enriched the text with 
some observations upon the structure of the organ as it exists in other animals. 

The structure and functions of the spleen have occupied the attention of an- 
atomists in a degree proportionate to the doubt which rests upon this organ. 
The result of their studies has been to unravel more thoroughly the intricacies 
of its organization, without, as yet, furnishing any positive information as to 
its uses in the economy. The most interesting facts mentioned in the volume 
before, us concerning this organ, are those which refer to its internal tunic. Dr. 
Sharpey has been accustomed to refer in his lectures to this coat, as containing, 
in addition to the interlaced bundles of cellular tissue mixed with fine elastic 
tissue, "pale, soft fibres, apparently plain unstripped muscular fibres, resem- 
bling those of the middle coat of the arteries." P. 498. Recently, too, Professor 
Kolliker has made many observations upon different animals, which have in- 
duced him to conclude that the spleen is a "muscular organ." "The mus- 
cular fibres are of the plain variety, and mixed with elastic or nuclear fibres. 
In some animals, as the pig, dog, and cat, they exist in the allugineous or proper 
coat, the sheaths of the vessels and the trabecule ; in the rabbit, they are want- 
ing in the coat; and in the ox, according to Kolliker, they are found only in the 
small-sized and microscopic trabecule, the rest of the trabecular structure and 
proper coat consisting merely of elastic and cellular tissue. He finds that the 
muscular tissue of the spleen is, for the most part, made up of short, pale, flat 
fibres, from ^ to y£ v inch long, having oblong nuclei. As to the human 
spleen, he could discover muscular structure neither in the proper coat, nor in 
the larger trabecule ; but the fine microscopic trabecule appeared to be made 



1849.] Reports of Births, Marriages, and Deaths. 163 

up of elongated cells, with round nuclei, which he is disposed to regard as ele- 
ments constituting a muscular tissue. He could obtain no unequivocal evidence 
of contraction, on irritating the spleen in recently killed animals/' P. 498. 

The urinary organs, and the organs of generation in both sexes, are treated 
of in the same comprehensive and detailed manner. And the work is closed 
with a chapter on the surgical anatomy of the walls of the abdomen and pelvis, 
with reference to the operations which may be required for the relief of hernia, 
and of stone in the bladder ; thus completing the remarks on the surgical re- 
lations of the different organs, — the arteries having been considered in this 
connection in the chapters devoted to the organs of the circulation. 

We close our notice of this work, expressing the gratification which we have 
derived from its perusal, and our conviction that all who consult it will feel 
similar satisfaction. F. W. S. 



Art. XXI.— Seventh Annual Report to the Legislature, relating to the Registry 
and Returns of Births, Marriages, and Deaths, in Massachusetts, for the year 
ending April 30th, 1848. By Wm. B. Calhoun, Secretary of the Common- 
wealth. 8vo. : pp. 56. 

Report of the Secretary of State, of the Number of Births, Marriages, and Deaths 
[in the State of New York] for the year 1847. 8vo. : pp. 56. 

The latter of these documents is, we believe, the first fruit of "An Act provid- 
ing for the Registry of Births, Marriages, and Deaths, " passed in April, 1847, 
by the Legislature of New York. We hail it with no small pleasure, as the 
harbinger of much interesting intelligence to be anticipated from the exten- 
sion of the registration system, over a great State, embracing a population 
of more than 2,000,000. It would be unreasonable to expect perfection at the 
outset, but this is a promising beginning. Massachusetts set the example 
many years ago. New York has succeeded, and other States are preparing to 
follow ; so that we may soon expect to have the system of registration spread 
over the largest portion of the United States. The reports, collated from the 
materials thus collected, cannot fail to furnish data of the highest value to the 
statesman, political economist, and philanthropist. They will show the exact 
condition of population in different places, and at different times, demonstrate 
advantages, where these exist, and lead to the detection and correction of evil 
influences, of whatever kind these may be. They will furnish the means of 
comparing the conditions of population at different periods, and thus not only 
serve the exigencies of the present day, but prove highly interesting to future 
generations. 

By the provisions of the New York registration act, the clerk of each school, 
district in the State is required to make returns to the town clerk of the town, 
(township) in which his district may be situated. The town clerk is required 
to report to the county clerk, and the latter-named officer reports to the Secre- 
tary of State. Blank forms, with instructions for making out the primary re- 
ports, were sent by the Secretary of State to the several county clerks, and by 
these last distributed to the town clerks. 

Reports have been received from every county in the State, although one or 
two were somewhat tardy in handing them in. It however appears, from the 
returns of the several county clerks, that many of the townships made no re- 
ports, and that the only city from which reports were received, is New York, 
and this only in part, namely, the usual bill of mortality. Consequently, the 
present report to the legislature will not constitute a full and complete return 
of the births, marriages, and deaths, in the entire State, for the year 1847. 

The whole amount of births reported, was 35,897; of marriages, 11,437; of 
deaths, 17,263. This statement of mortality only includes the returns from the 
interior of the State, to which we may add the amount of the city of New York, 
15,788; making the sum total of deaths reported, 33,051. This, of course, is 
far short of the actual mortality. But for many places the returns are so full 
as to be highly valuable, the diseases causing death being given, and the ages 



164 



Bibliographical Notices. 



[July 



at death stated. The statician would certainly desire fuller information, but, in 
its absence, will be glad to receive even these partial data. Massachusetts, 
which has been rendering annual reports for seven years, still exhibits a very 
great deficiency in the amount of mortality. In 1847, the sum total of deaths 
reported through the registration returns, is 11,063. Now, supposing the popu- 
lation of the entire State to be in that year 850,000, this would give only 1 death 
to 77 inhabitants ; a ratio far below what may be expected, when complete returns 
shall be procured. The returns of mortality for the whole State of New York, 
for 1847, amounting to 33,051 deaths, gives only 1 death to about 82 inhabitants, 
supposing the entire population to be 2,750,000. As the true rate, according to 
the most favourable estimate, is probably not less than 1 death per annum in 
every 45 of the population, the return made for 1847 represents only about half 
the actual mortality. 

It must be observed that this report of the births, marriages, and deaths, in 
the State of New York, is so made as to constitute two distinct documents. 
One of these is the Report of the Secretary of State for the several counties in 
the interior ; the other, the Annual Report of the City Inspector of New York, 
including merely the bill of mortality for that city. This last has already come 
under our notice, in previous numbers of this Journal. We shall, therefore, 
restrict ourselves to the registration returns for the interior of the State. 

Births. — Of the 35,897 births reported for 1847, from the several counties in 
New York, the males constitute 18,722 ; the females, 16,988. In 187, the sex is not 
given. There were 242 black males, 225 black females ; and, in 695 births, the 
complexion was not designated. Fifteen pair of twins, and 118 illegitimate 
births are reported. 

The highest number of births occurred in August, viz. 3,370, and the fewest 
in January, viz. 2,327. The respective amounts for the different months stand 
as follows : — 

January, 

February, 

March, 

April, 

May, 

June, 

In 83 cases the month is not stated. 

Marriages. — Of the 11,437 marriages reported, by far the largest number 
occurred in the fall and first month of winter, and the smallest amount in the 
spring months, as will be seen by the following statement exhibiting the pro- 
portions for each month : — 

January, 
February, 
March, 
April, 

May, 
June, 



2,327. 


July, 


3,243. 


2,501. 


August, 


3,370. 


3,079. 


September, 


3,301. 


3,000. 


October, 


3,202. 


2,974. 


November, 


2,940, 


2,860. 


December, 


3,016. 



898. 


July, 


942. 


841. 


August, 


770. 


820. 


September, 


1,238. 


612. 


October, 


1,354. 


701. 


November, 


1,151. 


730. 


December, 


1,348, 



Of the persons married, there were 

3,338 under 20 years. 
5,383 between 20 and 25 



4,292 


(< 


25 " 


30 


1,300 


<« 


30 " 


35 


753 


it 


35 " 


40 


415 


it 


40 " 


45 


260 


it 


45 " 


50 


178 


a 


50 " 


55 


113 


it 


55 " 


60 


74 


a 


60 " 


65 


119 


it 


65 " 


70 



years. 



8 over 70 years. 
3,641 ages not given. 



1849.] 



Reports of Births, Marriages, and Deaths. 



165 



Deaths. — Of the 17,263 deaths reported from the several counties, 8,613 were 
of males, and 8,575 of females. In 75 cases, the sex is not given. The deaths 
of blacks constituted 190 males, 204 females. In 591 cases, the complexion is 
not stated. 

Of the conditions in life of the deceased, it is mentioned that 3,352 were mar- 
ried males, 2,917 married females, 5,400 unmarried males, 4,318 unmarried 
females. In 1,276 cases the condition is not given. 

In 15,290 deaths, reported from various specified causes, 7,726 were males, 
7,564 females. The male deaths in the first year of life were 1,033, the female, 
833. 



Of the deaths from 1 to 2 years, there were 



2 " 


5 


5 " 


10 


10 " 


15 


15 " 


20 


20 " 


25 


25 " 


30 


30 " 


40 


40 " 


50 


50 " 


60 


60 " 


70 


70 " 


80 


80 " 


90 


90 " 


100 



Males. 
590 

818 
418 
211 
276 
431 
390 
535 
494 
502 
508 
579 
391 

89 

15 



Females. 

584 
723 
407 
236 
432 
537 
445 
672 
514 
445 
503 
546 
295 

71 

12 



" 100 and upwards 

Ages not designated, 755. 

In one of the tables, there are about eighty different professions and occupa- 
tions of the deceased given, from which the average duration of life of the seve- 
ral callings, is estimated. But the number of cases is much too limited to 
afford, in most instances, even an approximation of the real value of life in the 
various occupations. We will, however, give a few of the details under this 
head. 

The average age at death, excluding all under 20 years, of 

36 clergymen, was 

18 lawyers, " 

57 physicians, " 

2706 farmers, 

13 saddlers, 

4 farmers, " 

30 shoemakers, " 

74 merchants, " 

535 mechanics, " 

90 school teachers, " 

70 carpenters, " 

1136 housekeepers, " 

22 weavers, " 

9 masons, " 

404 labourers, " 

The diseases which proved 
lows : — 

Apoplexy, 

Enteritis, 

Congestion of the brain, 

Dropsy of do. 

Inflammation of do. 

Bronchitis, 

Cancer, 



56 years. 


36 milliners, 


30 years 


44 ' 




5 pensioners, " 


84 ' 




51 < 




251 servants, " 


44 ' 




57 < 




60 seamstresses, " 


31 ' 




43 < 




44 blacksmiths, " 


38 ' 




66 < 




33 boatmen, 


33 < 




54 ' 




50 tailors, 


37 ' 




38 < 




11 painters, 


49 ' 




44 < 




28 tailoresses, " 


33 ' 




28 < 




7 printers, " 


29 ' 




49 < 




34 sailors, " 


40 < 




44 ' 




11 millers, 


46 ' 




57 < 




1 grass widow (?) " 


35 ' 




45 < 




9 wheelwrights, " 


48 < 




41 < 








most 


fatal, in 15,290 designated cases, 


were as fo 




Males. Females. 


Total. 




99 86 


185 




193 154 


347 




26 23 


49 




118 126 


244 




230 203 


423 




30 27 


57 






58 78 


146 





166 



B 


ibliographical Notices. 




& 




Males. 


Females. 


Total. 


Casualties, 


319 


108 


427 


Childbirth, 




101 


101 


Cholera infantum, 


41 


35 


76 


Cholera morbus, 


28 


23 


51 


Bilious colic, 


36 


16 


52 


Consumption, 


1,388 


1,942 


3,330 


Convulsions, 


59 


52 


111 


Croup, 


300 


264 


564 


Delirium tremens, 


41 


1 


42 


Diarrhoea, 


142 


141 


283 


Diabetes, 


17 


10 


27 


Dropsy, 


299 


365 


664 


" of chest, 


9 


9 


18 


Drowned, 


38 


9 


47 


Dysentery, 


370 


348 


718 


Epilepsy, 


7 


13 


20 


Erysipelas, 


59 


86 


145 


Fever, 


224 


220 


444 


" Bilious, 


120 


87 


207 


" Congestive, 


19 


18 


37 


" Intermittent, 


10 


5 


15 


" Puerperal, 




28 


28 


" Remittent, 


9 


7 


16 


" Scarlet, 


231 


214 


445 


" Typhus, 


215 


163 


378 


" Ship, 


60 


48 


108 


Fits, 


149 


121 


270 


Gravel, 


35 


1 


36 


Heart, disease of, 


94 


72 


166 


" dropsy of, 


9 


10 


19 


" enlargement of, 


8 


5 


13 


Hemorrhage, 


12 


12 


24 


" of lungs, 


7 


2 


9 


" uterine, 




2 


2 


Inflammation, 


144 


111 


255 


" of the lungs, 


328 


276 


604 


Insanity, 


9 


7 


16 


Intemperance, 


63 


4 


67 


Liver complaint, 


66 


43 


109 


Lockjaw, 


12 


3 


15 


Measles, 


99 


122 


221 


Old age, 


386 


386 


772 


Palsy, 


102 


97 


199 


Scrofula, 


51 


39 


90 


Small-pox, 


48 


21 


69 


Still-born, 


20 


20 


40 


Suicide, 


32 


10 


42 


Summer complaint, 


44 


43 


87 


Unknown causes, 


477 


502 


979 


Varioloid, 


2 


1 


3 


Whooping-cough, 


80 


100 


180 


Worms, 


25 


30 


55 



The table, from which the above extracts have been made, has evidently not 
passed through the hands of any one qualified to put it into a desirable shape. 
Certainly no one connected with the medical profession could have had a hand 
in drawing it up, still less, any one acquainted with the nomenclature and 
classification recommended by the American Medical Association. 

Deaths from similar diseases are placed under different heads, and we have 
the names of diseases hard to conjecture — such as "nervousness" "spine" "St. 
Anthony's dance' 7 "rattles;" St. Anthony's dance is perhaps intended for St. 



1849.] Reports of Births, Marriages, and Deaths. 167 

Vitus's dance, or chorea. But still, with all the faults, we are glad to get hold 
of details, as they enable us to draw comparisons between the mortality of dis- 
eases in the country, and cities, with the last of which we have been long 
familiar. On this account we have drawn more largely upon the table, showing 
the causes of death, than perhaps comports with the nature of our notice. 

We now proceed to the Massachusetts document, which embraces the regis- 
tration period of one year, ending April 30th, 1848. Considerable deficiencies 
are still apparent in the execution of the registration law in this State, notwith- 
standing the time that has elapsed since its first adoption, and the intelligence 
brought forward to promote its operation. The primary statements reported 
from the several towns, are accompanied with a great many notes which indi- 
cate a strong interest in the cause, and a desire to have the system perfected. 
Who could believe that the city of Boston, so far-famed for the intelligence of 
her citizens, would be open to such a charge as is implied in the following 
paragraph from the report of the Secretary of State of Massachusetts. 

" The continued neglect of the city of Boston, to aid the government in the 
accomplishment of the invaluable purpose contemplated by the law, ought not 
to be overlooked. This neglect cannot be in consonance with the intelligence 
and wisdom which are so conspicuous in the noble and enlightened public 
spirit of Boston. The bearing of the results and facts, sought for by the re- 
quirements of the law, on interests of indisputable importance, cannot fail to 
be seen by all thoughtful observers." 

"To improve man's physical condition/' continues the Secretary, " and thus 
to contribute to his moral advancement, is the great purpose of the statistical 
views and facts, which the law in question strives to bring to light. More than 
ever important does this purpose become at the present moment, when our com- 
monwealth and country lie open to unlimited emigration from the Old "World. 
Unspeakably interesting and vital should this view of the subject be to the city 
of Boston." 

Births. — The table giving the births in the several counties for each month 
in the year, shows that, of the total amount 16,322 reported, 8,115 were males ; 
7,882 females ; 140, sex not stated ; 82 males, and 77 females, for which the month 
of birth is not given. The amount reported for each month is as follows : — 





Males. 


Females. 


Not designated. 


Total. 


January, 


655 


678 


17 


1350 


February, 


750 


731 


20 


1561 


March, 


790 


723 


15 


1528 


April, 
May, 


732 


700 


20 


1452 


614 


551 


9 


1174 


June, 


541 


551 


9 


1101 


July, 


613 


657 


10 


1280 


August, 


698 


657 


6 


1361 


September, 


717 


713 


7 


1437 


October, 


675 


684 


7 


1366 


November, 


644 


616 


7 


1267 


December, 


686 


621 


13 


1320 



It thus appears that the highest number of births occurred in the month of 
March, and the lowest amount in June ; February, March, and April all make 
monthly returns far above the average. Reverting to the months in which the 
conceptions took place, nine months previous, we find the corresponding months 
of conception to be May, June, and July. The offspring of plurality-births 
amount to 308, of which 140 are designated as males, and 161 females. 

Marriages. — Of the 5,287 marriages, the highest number in any one month 
was 760 in November, and the lowest 278 in July. 

There are tables exhibiting the ages of the marriages between bachelors and 
maids (3,869) ; bachelors and widows (111) ; widowers and maids (510) ; widow- 
ers and widows (200). 

The instances where both parties were under 20, are only 47. The most mar- 
riages took place between the 20th and 25th year. Namely, of 705 men between 



168 Bibliographical Notices. [July 

20 and 25 to 705 women under 20 ; 950 men between 20 and 25 to 950 women 
between 20 and 25 ; 115 men between 20 and 25 to 115 women between 25 and 
30. Of the marriages of men between 25 and 30, 252 occurred where the women 
were under 20 ; 662 where the women were between 20 and 25 ; 284 where the 
women were between 25 and 30 ; 23 where the women were between 30 and 35. 
Of the marriages of men between 30 and 35, 38 occurred where the women were 
under 20 ; 112 where the females were between 20 and 25 ; 80 where the females 
were between 25 and 30 ; 30 where the females were between 30 and 35. 

Deaths. — The abstract of the returns of deaths are given in very convenient 
forms, which we recommend as examples to our New York friends who may be 
charged with making out tabular statements of an additional year. There is first 
a table showing the diseases which proved fatal, the sexes and ages of the de- 
ceased, with the month when the deaths occurred, together with the places of 
birth. The diseases causing the deaths are arranged in alphabetical order, 
which is exceedingly convenient for reference. Then follow other tables, in one 
of which the causes of death in the several counties of the State are arranged, 
according to the classification recommended by the American Medical Associa- 
tion ; whilst in another the causes of death are compared with those reported in 
the two previous years, 1846, 1847. The convenient form and interesting views 
presented in these tables reflect great credit on those concerned in making them 
out. The concise views presented are the results of much patient labour, as 
any one acquainted with the nature of statistical calculations will readily per- 
ceive. From the tables presenting the causes of death in the rural population 
of Massachusetts, and also that showing the influence of occupations over the 
chances of life, we should be glad to extract many of the interesting facts dis- 
played, but cannot now do so, having already infringed too much upon the space 
allowed for a bibliograph. G. E. 



Art. XXII. — On the Cryptogamous Origin of Malarious and Epidemic Fevers. 
By J. K. Mitchell, A. M., M. D., Professor of Practical Medicine in the Jef- 
ferson Medical College of Philadelphia. Philadelphia 1849 : 8vo., pp. 137. 
Lea & Blanchard. 

The origin of the several forms of fever that ordinarily prevail as endemics, 
in particular localities, or spread, occasionally, over extensive districts, as de- 
structive epidemics, has ever been a subject of curious inquiry to the patholo- 
gist. To account for the production and spread of these diseases ingenuity has 
been taxed in the formation of plausible hypotheses, in evidence of the truth of 
each of which an array of apparently incontrovertible facts and cautious obser- 
vations has been adduced by its author and advocates. Important, however, as 
is the subject, and industriously as it has been pursued, no one of the theories 
that have been heretofore advanced, can be considered as satisfactory, and we 
have still to confess our ignorance of the nature of the morbific cause to which 
fevers, whether endemic or epidemic, owe their origin. We may, it is true, be 
able to indicate, with some degree of certainty, a few of the leading circum- 
stances under which one or other of the forms of fever is most liable to occur, 
but still the entire subject of the etiology of this class of diseases is open to in- 
vestigation — and the demonstration of the cause by which they are produced, 
may still crown with fame the name of some industrious inquirer. 

In the volume before us, Dr. Mitchell has announced a theory of the origin 
of malarious and epidemic fevers, which, if it be not entirely original with him, 
he will have the credit of having defended and illustrated by a series of facts 
and arguments as plausible, and apparently as conclusive, to say the least, as 
those upon which are based either of the theories that have preceded it. He 
has presented, in bold relief, the leading defects of the explanations generally 
received, and has attempted, with much ingenuity, to show that these defects 
are satisfactorily supplied by rejecting the common doctrines of the causes of 
malaria, and adopting the cryptogamous plants generally as the chief agent in 
its production. 



1849.] Mitchell on the Origin of Malarious and Epidemic Fevers. 169 

"Of the cryptogamous plants, the fungi," Dr. M. remarks, "are distinguished 
for their diffusion and number; for their poisonous properties, and their peculiar 
season of growth ; for the minuteness of their spores, and for their love of dark- 
ness and tainted soils, and heavy atmospheres." 

But while he presents the claims of the fungi as the principal cause of fevers, 
our author does " not mean to exclude the occasional agency of other crypto- 
gamous vegetables." 

Dr. M. is not so presumptuous as to suppose that he has, in the volume before 
us, fully demonstrated the truth of the doctrine he advocates. In undertaking 
the adventurous duty of developing a theoretic result, he does not expect " to 
do more than obtain for it, at present, a hearing and an examination ; since its 
demonstration, if ever completed, must exact, for years, the enlightened and 
patient toils of many philosophers." 

"Imitating," he remarks, "the natural philosophers, I have constructed a 
theory, not to be esteemed devoutly true, but as, in the present state of know- 
ledge, the most perfect explanation of the known phenomena of the case ; and 
as the least exposed to the many objections easily brought against any other 
hypothesis." 

During a careful perusal of the several chapters in which the doctrine of the 
cryptogamous origin of fevers is developed by our author, we were often struck 
with its great plausibility, and the numerous phenomena connected with the 
history of epidemics, hitherto unexplained, which it readily and, apparently, 
correctly accounts for. That the doctrine is attended with difficulties is not, 
however, to be concealed. Some of the leading objections to it are noticed by 
Dr. Mitchell, and attempted to be removed. 

One of these objections is, " that the cause assigned is not adequate to the 
rapid production of the effect." That it is not probable that a minute vegeta- 
ble, however distributed, can contaminate the air of a large marsh or field, in 
the course of a few minutes or hours. To this Dr. M. replies — 

" When we remember how minute a quantity of a reproductive organic virus 
is, in other cases, necessary to the infection of a proper subject, we might leave 
the argument to that defence alone ; but I think there is a better one, in the 
wonderful growth and ready diffusion of the plants to whose nocturnal potency 
I am inclined to ascribe malarious fevers. 

"A mushroom growth is proverbial, in every language. In a single night, 
under favourable circumstances, leather, or moist vegetable matter, may be 
completely covered with mould. Of the more minute fungi, some species pass 
through their whole existence in a few minutes, from the invisible spore to the 
perfect plant. Lind says, that the first rains in Guinea, have been known to 
make the leather of shoes quite mouldy and rotten in forty-eight hours ; show- 
ing that the plants which disorganize the leather must have drawn their nutri- 
tion, even from its heart, in that time, and, by many successive generations, 
extended themselves over its total surface. Mr. Berkeley describes a Polyporas 
squamosus which, in three weeks, acquired a circumference of seven feet, five 
inches, and a weight of thirty-four pounds. The Polyporas frondosus described 
by John Bapt. Porta, sometimes transcends a weight of twelve pounds in a few 
days. The Bovista giganteum, on the authority of Carpenter, the eminent phy- 
siologist, has been known to increase in a single night, from a mere point, to 
the size of a large gourd, estimated to contain four thousand seven hundred 
millions of cells ; a number which, when counted at the rapid rate of three 
hundred per minute, or five per second, would take the whole time of one per- 
son, night and day for three hundred years. A square mile contains upwards 
of 3,000,000 square yards, or 27,000,000 square feet, so that a single Bovista 
giganteum may present, at evening, an almost invisible cell, and yet place, be- 
fore morning, nearly 1,800 such cells in every square foot of a square mile. 

" Notwithstanding the wondrous productions of a single individual of one 
species, Fries, the Swedish naturalist, observed not less than two thousand spe- 
cies, within the compass of a square furlong. The same author tells us, that 
he has counted above 10,000,000 of sporules, in a single individual, of the Reti- 
cularia maxima, so minute as to look like smoke as they rose in the air. 

" Webster, when writing of the malignant fever of 1795, informs us, that 



170 Bibliographical Notices. [July 

sound potatoes from market, perished, in his cellar, in thirty-six hours ; and we 
know now how they perished. It was a parasitic death. 

" In the Philosophical Transactions, Lond. (vol. iv. p. 308, Abridg.), it is 
stated, that a green mould attacked a split melon, and took three hours to 
sprout, and six to ripen and produce, and let fall new seeds. 

" At New York, during the pestilential season of 1798, Webster says, that 
he saw a cotton garment covered with dark gray-coloured spots of mildew in 
a single night, and that such events were, then and there, common. 

" I might multiply examples of the rapid growth and extensive diffusion of 
fungi, which, like the lowest class of animals, seem to have a power of develop- 
ment and propagation inversely as their magnitude. The more minute the 
plants, the more rapid their multiplication ; until, as they descend to those of 
the smallest scale, a microscope shows them in even visible growth. Nothing 
astonishes one more than to see in the bottom of a watch-glass, a drop of yeast 
swelling up, as the torula cerevisiaz unfolds itself, and exhibits a forest of fungi, 
where, but a few minutes before, only a spore or two were visible." 

Another objection to the cryptogamous origin of malarious fevers is, the dif- 
ficulty of accounting for the specific identity of these in all climates, while 
the plants of temperate differ from those of tropical regions. 

To this our author replies, that the fungi are the natural inhabitants of all the 
various climates of the earth. " Like man, the fungi generally live in any cli- 
mate, though there are among them some that infest only the steppes of Tar- 
tary, and others that revel solely on the sands of Zahara. This ubiquity is one 
of their most peculiar qualities." 

" But why is it then," Dr. M. remarks, " if the same fungi create diseases in 
Lapland and Senegal, that there is so fatal a difference in the intensity of them 
at these two places ? As the fungi of a poisonous character possess acrid and 
narcotic properties, it is scarcely necessary to consistency to presume that the 
same are everywhere the cause of malarious fevers. Yet, if that were an impe- 
rative supposition, it would not embarrass the question materially, because 
naturalists affirm, that the poisonous cryptogami are rendered yet more poisonous 
by increased temperature and moisture." 

In reference to the objection drawn from the supposed difficulty of the spo- 
rules of the fungi passing into the circulation by the lacteals, absorbents, or 
the pores of the venous radicles, our author states that he has found them to be 
at least ten times as small as the chyle globules ; consequently, there can be no 
difficulty in their absorption, so far as their magnitude is concerned. As to the 
selective power of the lacteals, and other absorbents, which may be supposed to 
present an impediment to the absorption of the sporules of the fungi. 

"We know," remarks Dr. M., " that they suffer very many and various poi- 
sons to pass into the circulation, and that, in this respect, they are much less 
particular than our fathers imagined. Besides this, we know that fungous 
growths, both in man and the lower animals, have been found in places, to which 
their germs could have gained access only by the circulation, or by imbibition. 
There is, therefore," he concludes, "no good reason for doubting that the spores 
of fungi find their way to the channels of the circulation, as do the cells of ex- 
anthematous diseases, and the virus of syphilis." 

After noticing the fact that the cause of the uniform excess of malarious dis- 
eases, at the end of summer and autumn, has been all along an interesting 
subject of discussion and wonder, he proceeds to point out the error of sup- 
posing that their general prevalence then is the result of the greater amount 
and activity of the decomposition of dead vegetable matter going on at this 
season — this decomposition being in fact the most active in May and June. 

"When, after the previous autumnal death, and the, disintegrating effects of 
winter frost, or soaking rains, the warmth and moisture of spring and early 
summer rapidly decompose the softened textures, to feed the tender spongioles 
of the swelling vegetation. The great chemists, heat, light, and moisture, are 
then most active ; and the dead relics of the former year, prepared by time, frost, 
and rain, are ready for the process of decomposition, as the electrical and vital 
agencies of the countless and thread-like radices open up their intended store- 
houses of nutrition. Although, therefore, almost every one has supposed that 



1849.] Mitchell on the Origin of Malarious and Epidemic Fevers. 171 

the autumn is the season of the greatest decomposition, that process is really 
conducted in the spring and early summer with a tenfold energy, as may be 
easily recognized by the extraordinary smell of the earth after a shower at this 
season. 

" Malarious diseases, therefore, are not probably the effect of ordinary vege- 
table decomposition, for they occur most when that is not at or near to its maxi- 
mum. Everywhere they abound, when the general vegetation has just passed 
through its great orgasm. But there is another and special vegetation, which, 
whatever may be the climate, has its spring time and summer in the autumnal sea- 
son of the year. On the exhausted debris, and the varied exuvice of plants, weeds, 
and grasses ; from root to leaf; under ground and above ground; feed a race 
of vegetables which wait for their food to the latest period of the season of heat, 
and then nourish most when the more perfect forms have completed their 
annual task, and submit to the inroads of these Goths of phytology." 

" The insalubrity of a place has the most constant relation to the habits of the 
living vegetation. Whatever may be the temperature or humidity, the most un- 
healthy period of the year is, in any given locality, that when the phaneroga- 
mous vegetation has completed its annual task of growth, and flowering, and 
fruitage, and feels the weakness of an exhausting effort ; and when to triumph, 
as it were over a worn-out foe, the crytogamous plants plunder and destroy it." 

The third lecture of Dr. M. commences with a notice of the fact that the most 
common malarious diseases are not producible by exposure in sickly places 
during the day time ; but that, whatever may be their cause, it seems to have 
activity almost solely at night ; — darkness appearing to be essential to either 
its existence or its power. The author then proceeds to point out the insuffi- 
ciency of the received theories, in the satisfactory explanation of this curious 
influence of night. Rejecting the several explanations that have been advanced, 
he remarks : — 

"But when we observe the extraordinary tendency of fungous vegetables to 
develop their power only at night, we detect another analogy between malaria 
and the fungi. In vain do we search in the latter part of a day for young mush- 
rooms. The early riser finds them in their prime and abundance. A field which 
at evening exhibited not a single plant, is often whitened by their little um- 
brellas in the morning. It is well known, writes Comstock, that this tribe of 
plants spring up almost everywhere, especially among decaying substances, 
and that thousands may be seen in the morning, where none existed the evening 
before. 

" Even the more durable kinds of fungi appear to add during the day little 
to thei,r bulk, preferring to grow almost solely under the eye of night ; so that 
these anomalous vegetables not only choose for their growth the seasofi of vege- 
table repose, but the hours of vegetable sleep. In another respect they are beings 
of contrast ; for, while other vegetables are adding oxygen to the air from which 
they have extracted its carbon, these, as if they were averse to agreeing with 
phenogamous plants in any respect, are eliminating carbonic acid, having ex- 
tracted from the undecomposed organic matter on which they live, its more 
peculiar animal elements, the hydrogen and nitrogen. 

"Supposing that the minutest fungi possess the general properties of the 
class to which they belong, we may readily perceive what prodigious influence 
must be exerted on them by the damp rich air of a swamp — and if they have, 
as Heasinger alleges, a polarizing membrane, and consequently electrical rela- 
tions to the polarized vesicles of a marsh mist, that mist, imbued with moisture, 
enriched by the terrestrial exhalations, and screened by the shadows of night, 
may form the most fruitful floating soil for the invisible cells of microscopic 
cryptogami: so that from the damp earth, or the nebulous air, or both, may 
come out, to propagate disease, the cells of an anomalous vegetation." 

To the objection that, even if the fungi do grow at night, they should, some- 
times at least, taint the day air of their vicinity, from which they can scarcely 
be entirely eliminated by an absorbing earth or a dissipating mist : Dr M. re- 
plies, by supposing that, if they have electrical relations to the mist, or ascend 
only during the night, the quantity necessary to produce morbid results may 



172 Bibliographical Notices. [July 

not remain during the day. Other reasons for the diurnal changes of salubrity 
in malarious regions, he bases upon certain habitudes of the fungi. 

The remainder of the lecture is devoted to an exposition of the extraordinary 
association, as remarked by various authors, of fungous life with the existence 
and propagation of great epidemics, and intense endemics. 

The subject of the fourth lecture is to prove that most of the fungi are poison- 
ous, and produce diseases resembling marsh fever. 

The author commences his fifth lecture by remarking that — "A theory of 
malaria should not, in this enlightened age, be received, which does not, at least 
plausibly, account for the apparent irregularities, seeming contradictions, and 
anomalous inconsistencies of the subject, which now so greatly obscure all the 
usual modes of explanation. In this respect I hope to show the very great su- 
periority of that which, I presume is, by this time, not unfavourably viewed by 
my hearers. The diffusion of the fungi ; their properties as a class ; their acknow- 
ledged power of producing diseases of a febrile character marked by periodicity ; 
their nocturnal power and autumnal prevalence ; their love of the damp, dark 
places in which febrile epidemics delight ; their obvious association with many 
cutaneous and some mucous diseases ; their production of some contagious dis- 
eases of insects ; and the progress of diseases from cattle, which are sickened 
by eating mildewed food, to human beings, sometimes by the use of the flesh, 
and sometimes, as in the cases reported by Vimat, by the simple exhalation of 
epidemic influence ; all these details, numerous, diversified, and well sustained 
by authorities, should, I hope, induce my auditors to advance into the subject 
of the present lecture with, at least, some partiality for the new doctrine." 

The cause of the latency of the malarious poison, Dr. M. conceives it is not 
easy to comprehend, unless we suppose that the poison received into the system 
is organic and vital, and that the phenomena of disease depend on its modifica- 
tion and reaction in the body. In this way, he remarks, we can also under- 
stand how such a poison may remain dormant, like some of the animal poisons, 
and that its absorbed germs may be stimulated not only by time but season, 
following laws which we are just beginning to study. He then adduces testi- 
mony to show that the poison of the fungi may remain apparently inactive 
for from an hour or two to even a clay and a half, and that, too, when swal- 
lowed in large quantities. 

"If," he inquires, "we were now to look for any known poison as explanatory 
of the latency of malaria, should we not be inclined to say, that only that of 
the fungi exhibited in this respect a strong analogy? We know of no other 
morbific agent whose action is so uniformly and irregularly postponed." 

The arrest of the progress of malaria by a low wall, a common road, or a 
screen of trees ; the exclusive prevalence of agues on one side of a street, and 
the progressive inroads of malarious diseases into certain localities, Dr. M. 
believes, can in no manner be so satisfactorily accounted for as by supposing 
the morbific poison to be a fungous one, progressively marching over the soil, 
sustained by the rich and pregnant moisture from the marsh. We can then 
understand why that the wall, or the road, or the wood, should limit its pro- 
gress ; besides which, the spores of all fungi are more or less electrical, and 
are, therefore, likely to be arrested by the trees of a wood. 

The fact that, in some cases, malaria is active only in the immediate neigh- 
bourhood where it originated, while in others it seems to be wafted to a great 
distance from its apparent source, is, according to our author, readily explained 
by supposing the existence of germs susceptible of reproduction and progres- 
sive growth. 

"The interruption of progress by a road or wall justifies this view of the 
mode of conveyance, and the many facts which show the narrow limits of the 
poisonous activity enforce it strongly. The place, the very spot, where the 
disease is found, must reproduce the cause of it for itself; and if the conditions 
of growth are not present, then will the spot be exempt, even if very near to 
the most poisonous places. Thus may we, and only thus, explain the occur- 
rence of agues, yellow fever, and cholera, on only one side of a house, or one 
end of a room, or one side of a street, or wall, or road. A wind may, indeed, 
waft the spores in small quantities to a distance, but unless there are there 



1849.] Mitchell on the Origin of Malarious and Epidemic Fevers. 173 

the conditions essential to an adequate reproduction, the spores must lie dor- 
mant and harmless. For such reproduction, the marsh mist may be one of the 
most important elements ; but that alone will not suffice, since we know that 
the disease is not proportional to its frequency or intensity. Other and very 
local conditions seem to exercise a peculiar power. Thus, a new house is known 
to resist disease better than an old one, and a residence protected by an annual 
cultivation immediately around it, is more safe than one which is encircled by 
lawns in grass. During some unusually sickly years, when scarcely an inha- 
bitant of the skirts of the city escaped marsh fever, the wind set, often for a 
long period, directly from the infected regions into the heart of the city. In 
perhaps half a minute from the time when the south-western air left the mea- 
dows and pestilential borders of the town, it had crept into every chamber of 
the place; yet physicians here, well know that no disease of a malarious cha- 
racter invaded these chambers, which were, most of them, left open during 
ever}- night of the sultry autumn. 

"Writers entitled to credit and authority, by position and professional charac- 
ter, assert, that a gauze veil, or a gauze screen in a window, adds much to the 
security of the wearer, or the occupant of a chamber, in even the most unsound 
places. We can scarcely see how any gas or vapour, simple or compound, could 
be arrested by such a defence ; but it is easy to suppose the detention of organ- 
ized and comparatively bulky bodies, electrical and glutinous or moist. 77 

By the cryptogamous theory of fever, Dr. M. explains, with much plausibility, 
the greater security from disease in malarious places, derived from artificially 
drying the air, and the reported exemption of cooks and smiths from the sweat- 
ing sickness ; there being no other poison save that of the fungi, so far as we 
know, which is thus disarmed of its virulence by dryness and heat. By the 
same theory, he explains the cause of danger from sleeping in mouldy sheets, 
and of the sternutation caused by turning over old books and papers. 

Upon no other theory can we, he believes, so satisfactorily account for the 
partial introduction of yellow fever, and other non-contagious malarious dis- 
eases, into places always otherwise exempted from them, by means of trunks 
of unwashed clothes, brought from infected regions. 

"Were," he remarks, "yellow fever a contagious disease, the examples of 
its propagation by fomites might be easily explained ; but as its non-contagious- 
ness is clearly shown by even stronger testimony than that cited in favour of 
its introduction by fomites, we are left to explain the difficulty, as best we may, 
consistently with a belief in its importation by trunks and clothes, and a tho- 
rough conviction of its total want of contagious power. There is left but one 
escape, and that lies in the supposition that fungi, when lodged in the trunks, 
among filth and animal matter, find, in darkness and dampness, the fittest ima- 
ginable growing place. That, in scarcely any of these cases, the disease ad- 
vanced beyond those who inspected or handled the clothes, is only proof of the 
usual difficulty of sowing successfully tropical seeds in temperate climates, and 
of the inaptitude of fungi to grow under any but the nicely adjusted conditions 
upon which many of the tribe rely.' 7 

Of a similar character, according to Dr. M., is the question of the importation 
of yellow fever in ships. 

"A tropical fungus, carried off in dark, damp, animalized holds of ships, or 
in the offensive clothes of sick or dead seamen, may, he supposes, be introduced 
into the summer clime of unaccustomed places, and there, as it came from, . 
may go to, the shore, and be sometimes reproductive. That the germs, when 
once ashore, may slowly migrate landwards, and even by chance be carried or 
wafted to other neighbouring spots, where they may grow, and create new foci 
of disease ; that the requirements of an exotic may make such visitations rare, 
and such dispersions unusual, and that the equatorial plants may be nipped 
and even totally destroyed by an unaccustomed frost. 

" Through this theory, we can easily see why the disease may be imported, 
why it is imported rarely, and why it makes so slow a progress from the spot 
to which originally brought. It will also explain its non-contagious character, 
and even its occasional but rare visit to a hamlet or village. It may also ac- 
count for its apparently spontaneous appearance in such places as Charleston, 
No. XXXV.— July, 1849. 12 



174 Bibliographical Notices. [July 

Savannah, and New Orleans, in which the winter may not be severe enough to 
kill the germs, but yet may so affect them as to make their reaction difficult or 
partial. 

" It is only thus that we can comprehend how a perfectly healthy crew may 
bring with them, in the closed hold of their ship, the germ of disease, which, 
after their dismissal, may pestilentially affect the ' stevedores' who discharge 
her, or only the labourers who disturb her ballast. We can thus, too, explain the 
usual pause between the first set of cases caught by visitors to, or labourers 
on board, the ship, and the attacks upon the inhabitants of the vicinity." — 
"This interval is only to be explained by the supposition that germs of some 
kind have gained a footing on shore, and have germinated and grown more nu- 
merous. It is the crop in the hold which produces the first set of cases. It is the 
crop on the land which causes the second. 

"It is only through the action of some organic cause, that we can explain 
the tenacity of the attachment of yellow fever to certain ships, and these, too, 
among the cleanest and best aired in the British service." 

By assuming for the cholera a fungous origin, Dr. M. is convinced, that all 
the peculiarities connected with the etiology of cholera may be readily explained. 
Its singular local origin ; its yet more singular progress ; its apparent incon- 
sistencies ; its diffusion from a tropical point over the habitable globe ; its 
invasion, in winter, of the frozen steppes of Tartary and Russia ; its solitary 
advance over untravelled wastes or untenanted seas, as well as the progress of 
the poison along the route of streams, and its preference for the damp parts of 
cities, are all accounted for by the assumption, that its producing cause, the 
semina morbi, are germs or spores of the cryptogami. 

"The cryptogamous theory," Dr. M. observes, in his recapitulation at the 
close of his sixth and last lecture, "will well explain the peculiar domestica- 
tion of different diseases in different regions, which have a similar climate — 
the plague of Egypt, the yellow fever of the Antilles, and the cholera of India. 
It accounts, too, for their occasional expansion into unaccustomed places, and 
their retreat back to their original haunts. 

"Our hypothesis will also enable us to tell why malarious sickness is dispro- 
portionate to the character of the seasons ; why it infests some tropical coun- 
tries and spares others ; why the dry Maremma abounds with fevers, while the 
wet shores of Brazil and Australia actually luxuriate in healthfulness. The 
prolonged incubative period, the frequent relapses of intermittents, and the 
latency of the malarious poisons for months, can only be well explained by 
adopting the theory of a fungous causation. 

" Finally, it explains the cause of the non-recurrence of very potent mala- 
dies better than the chemical theory of Liebig, and shows why the earliest 
cases of an epidemic are commonly the most fatal." 

Our great object, in the short analysis we have thus presented to our readers 
of the work of Dr. Mitchell, has been to present an outline of the doctrine of 
the origin of malarious fevers, advanced by the author, and a general idea of 
the manner in which he has explained, by the agency of poisonous fungi, and 
the other cryptogami, the causation of diseases of a febrile character. To 
appreciate fully the validity of the arguments and facts upon which the author 
has based his views, the whole work must be read with attention ; and as it is 
one calculated to interest, if it does not convince the reader, there will be few, 
we suspect, who will not be inclined to follow the author, step by step, in his 
"excursions into this new field of mingled reason and fancy." 

The cryptogamous theory, even though it should not be established as the 
true explanation of the origin of malarious and epidemic fevers, by the results 
of future and more extended investigation, is, at least, ingenious and plausible. 
Its conception, and the skill with which it is developed and sustained, are 
highly creditable to its author, with whom we almost feel inclined to admit, that, 

"It is the most consistent with the phenomena known at present, and much 
better sustained by established facts than any other hypothesis yet presented 
to the world." That "it has, therefore, the requisites of a philosophical theory 
which, in other and more exact sciences, would be accepted, not to be held as 
absolutely true, but as, in the present state of our knowledge, the most plausi- 
ble and convenient explanation of the phenomena." D. F. C. 



1849.] Day on Diseases of Advanced Life. 175 



Art. XXIII. — A Practical Treatise on the Domestic Management and Most 
Important Diseases of Advanced Life ; with an Appendix, containing a Series 
of Cases illustrative of a new and successful mode of treating Lumbago and 
other forms of Chronic Rheumatism, Sciatica and other Neuralgic Affections, 
and certain forms of Paralysis. By George Day, M. D., Fellow of the Royal 
College of Physicians, and Physician to the Western General Dispensary. 
8vo. pp. 226. Philadelphia : Lea & Blanchard, 1849. 

The means calculated to preserve the health, augment the comforts, and pro- 
long the life, of the aged, as well as to ward off, if* possible, that state of help- 
less decrepitude and second infancy which so often precedes, for a longer or 
shorter period, the' final departure of those whose life has been extended to its 
utmost limits, is a subject worthy the investigation of the enlightened physician 
— equally so are the nature and treatment of the diseases most liable to occur 
in the advanced periods of existence, and render burdensome the remnant of 
life, or precipitate the hour of dissolution. 

The important modifications which age produces in the character, pheno- 
mena, progress, and termination of diseases, have been pointed out by patholo- 
gists, while the therapeutist has indicated the precautions demanded in the 
application of our remedial agents, when, with the decline of life, the energies 
of the principal organs become impaired, and the regular and active perform- 
ance of the several functions commences to flag. 

Upon the hygiene and diseases of advanced life — as important and interest- 
ing as these subjects are confessed to be — we have, with the exception of the 
Practical Treatise of Dr. Day, no work in the English language in which the 
facts and observations that have been accumulated in relation to them are pre- 
sented in a form adapted for study and reference. As Dr. Day correctly re- 
marks, they have " been strangely overlooked, during the last half century, by 
the physicians of all countries — although many valuable essays and monographs 
on individual points connected with them lie scattered among the French and 
German periodicals, only one systematic work, that of Constatt, (Die Krank- 
heiten des hdheren Alters und ihre Heilung. Erlangen, 1839,) has been written 
during the period indicated." 

Many thanks, therefore, ar*e due to the author of the work before us, for 
having given his aid to supply the deficiency complained of. From the facts 
and observations derived from his personal experience, and from those recorded 
by other labourers in the same field, Dr. Day has been enabled to present a 
very able sketch of all the leading points connected with the hygienic manage- 
ment of the aged, and of the pathology and treatment of the principal diseases 
to which they are liable. 

The work, though somewhat concise, contains much valuable matter — from 
which the young practitioner especially will gain many valuable hints to guide 
him when called upon to minister to the comforts or relieve the ailments of 
such as are in the decline of life. 

The first four chapters, which treat on some of the most important changes 
occurring in the system in advanced life — on the preservation of health, and 
on the medical treatment generally during the period of old age, are replete 
with sound observations and judicious practical directions. The author's hy- 
gienic rules for the aged are admirable throughout, while his remarks on the 
effects, which, in the latter stages of existence, result from the action of the 
ordinary remedial agents, are evidently the result of close observation, guided 
by correct views as well pathological as physiological. The fifth chapter, on 
senile marasmus or wasting, can be considered only as a continuation of the 
fourth — for, as the author well remarks, true senile marasmus is not so much a 
disease as the gradual — physiological — wasting of the system — the true decay 
of nature. And although we may be able to alleviate the symptoms by well 
directed hygienic means, we cannot cure the disease, for it is the natural dis- 
ease of death. 

We extract from chapter sixth the following statements in reference to the 
diseases most fatal to persons in advanced life. 



176 



Bibliographical Notices. 



[July 



" In the first chapter, I mentioned incidentally many of the affections to which 
the changed state of the system rendered persons of advanced life especially 
liable. We must bear in mind that there is a wide difference between the most 
common and the most fatal diseases. It is of the latter that we are now treat- 
ing. On referring to the Registrar-General's tables for the last five years — from 
1843 to 1847 inclusive — I have found that the total number of deaths of persons 
aged 60 or upwards, occurring in the metropolis during that period, amount to 
63,048. Of these, 15,136, or about two-sevenths, are recorded as dying from 
the effects of old age. I have no doubt that, if a proper examination after death 
was always insisted upon, the number would be wonderfully lessened, for very 
few die from sheer old age. But taking these numbers as we here find them, 
there are left 47,912 cases of death from actual disease. 

"Death is ascribed to disease of the respiratory organs in 12,598 cases ; to 
diseases of the nervous system in 6947 cases ; to diseases of the digestive sys- 
tem in 3,141 cases ; and to diseases of the circulating system in 2,841 cases. 
Besides these, we have 1076 recorded cases of diarrhoea, 748 of influenza, and 
417 of erysipelas. 

"The following table gives the comparative frequency of the causes of death 
at and after 60. 

" Of 1000 persons who have attained that age, there die of old age 285. 

' Bronchitis . 



Diseases of the respiratory organs 

Diseases of the nervous system 
Diseases of the digestive system 
Diseases of the circulating system 



Asthma . . 
Consumption 
Pneumonia . 
Hydrothorax 
Other diseases 
f Apoplexy 
< Paralysis • . 
Other diseases 



Diarrhoea 
Influenza 
Erysipelas 



f Diseases of heart 
< Pericarditis . 
( Aneurism 
. . . . t . 



old age 
79.3" 
62.4 
35.7 
27.1 
10.4 
22.6 
53.0 
51.2 
26.7 



51.3 
1.3 
0.9 



Other diseases 



237.5 

130.9 

59.2 

53.5 

20.3 
14.2 

7.8 

808.7 
191.3 

1000. 

" The remaining 191.3 in the 1000 is made up, in a great measure, of cases 
of typhus and dropsy (neither of which have been tabulated by me, because 
the former is made to include all cases of continued fever, and because the 
latter is a symptom and not a disease, and may arise from very different 
sources); of cases of diseases of the urinary organs, of cholera, dysentery, 
cancer, gout, rheumatism, &c." 

In his consideration of the several diseases of advanced life, Dr. Day com- 
mences with the diseases of the respiratory organs, and then treats in succes- 
sion of those of the nervous, digestive, and circulating systems, the diseases 
of the genito-urinary organs, those of the skin, and, finally, the diseases of 
uncertain or variable seat, as gout, rheumatism, &c. 

The author does not profess to give comprehensive essays on the various 
diseases embraced in the present treatise ; but merely to explain the modifica- 
tions that advanced life impresses on the different symptoms, and to point out 
the peculiarities in the mode of treatment that should be adopted during the 
declining period of the vital power. His remarks in reference to these two 
important particulars are always judicious, and are well adapted to facilitate 
the establishment of a correct diagnosis, and to lead to the most successful plan 
of treating the maladies of the aged. 



er of cases. 

18 


Population at this age; the whole 
population being 20,000. 

3000 


Proportion of cases in 
1000 persons. 

6.0 


14 


2500 


5.6 


28 


1800 


15.5 


33 


1300 


25.4 


50 


1000 


50.0 


64 


500 


128.0 


14 


200 


70.0 



1849.] Day on Diseases of Advanced Life. 177 

As a specimen of the manner in which the diseases of advanced life are 
treated of by our author, we present the following extracts from his section 
(sect, iii.) on Cerebral Softening. 

''Although cerebral softening may occur at any period of life, it undoubtedly 
claims to be regarded as essentially a disease of advanced age. The cases on 
which the following table is based are 221 in number ; they are collected from 
the writings of Andral? Rostan, Bouillaud, Dechambre, Durand-Fardel, Fuchs, 
and Lallemand. 



20 to 30 
30 to 40 
40 to 50 
50 to 60 
60 to 70 
70 to 80 
80 and upwards 

If the number of cases on record were larger, we should probably find that 
the proportional number occurring at and after the age of eighty, was higher 
than at any earlier period of life. Some conception of its frequency may be 
formed, from the circumstance that, out of one hundred and one cases of death 
from diseases of the nervous system, observed by Prus, twenty-three were due 
to cerebral softening. 

" Acute softening appears, in more than half the recorded cases, to present 
no premonitory symptoms, and to induce loss of consciousness, and paralysis 
in the same sudden manner as cerebral hemorrhage. This is termed the apo- 
plectic form. In other cases, its invasion is solely marked by a general or par- 
tial, but progressive weakening of the intellectual faculties, and by various 
modifications of sensation. When premonitory symptoms occur, they usually 
present themselves as intense headache, vertigo, formication, cramps, &c. 

"In persons of sixty and upwards, the apoplectic form is the most common ; 
there is sudden loss of consciousness, contortion of the features, and the limbs 
on one side are rendered more or less insensible to external impressions, and 
either lie immovable and devoid of all power, or else are powerfully flexed. 
Persons thus attacked often die in a few days without any return of conscious- 
ness; but in the majority of cases consciousness gradually returns, and the use 
of the paralyzed parts is, to a certain degree, restored. This apparent improve- 
ment is, however, transitory and deceptive, for a progressive torpor of the 
intellectual faculties is soon perceived, while the paralysis extends and becomes 
more perfect, and the patient, if not cut off by some of the complications to 
which I shall presently refer, dies in a state of coma. 

"As the softening progresses, we sometimes (in about a quarter of the cases) 
have a considerable amount of frontal headache. Dullness of the intellectual 
faculties and loss of memory are almost invariably to be observed ; the mouth 
is drawn on one side, and there is often strabismus. Patients complain of 
cramps, pains, a sensation of cold and formication in some of the limbs,^ and 
sometimes there is partial paralysis. Contraction of one or more of the limbs 
is a symptom, whose importance has, I think, been overrated by Lallemand and 
some other authors. It certainly does not occur in half the cases of which we 
have authentic records. 

"Those who have made cerebral softening their especial study, assert that a 
very opposite class of symptoms is occasionally noticed ; that there may be 
cerebral excitement, violent delirium, and convulsions. 

"The rapidity with which the disease runs its course is sufficiently obvious 
from the following table founded on fifty-nine cases (twenty-seven of Durand- 
Fardcl, sixteen of Rostan, and sixteen of Andral): — 

"Death occurred 11 times during the first two days. 
" 26 times before the fifth day. 

43 times before the ninth day. 
7 times between the ninth and the twentieth days. 
9 times betweon the twentieth and thirtieth days. 



178 Bibliographical Notices. [July 

" Death is seldom preceded by any febrile symptoms. It occasionally happens 
that the disease merges into the chronic form ; and sometimes, but very rarely, 
there is a gradual remission of the symptoms, and a restoration to perfect health. 

" Chronic softening presents the same class of symptoms as those we have 
already described. In the majority of these cases, the patient complains of a 
feeling of discomfort, headache, vertigo, and stupor, which may last for weeks 
and months ; then follow more marked symptoms — difficulty in speaking, numb- 
ness, formication or pricking of the limbs, and especially of the fingers, partial 
loss of power and motion, shown, for instance, in one leg dragging in walking, 
or in the inability to grasp objects firmly. 

" Contraction of the limbs, in these chronic cases, is much more frequent than 
entire loss of power, whereas the reverse holds good in acute softening: it 
must not, however, be regarded as a constant symptom, being absent in at least 
one-fourth of all the recorded cases ; neither must it be regarded as a certain 
diagnostic sign of this disease ; it is met with in connection with disease of the 
membranes, without any affection of the cerebral substance, in cases of mere 
cerebral irritation, &c. Pains in the limbs and joints generally accompany 
these contractions; they are usually much aggravated by motion, but not 
increased by pressure. There is commonly a partial, but scarcely ever a 
perfect loss of sensation in the paralyzed and flexed limbs. The face becomes 
partially drawn aside, and the features are devoid of expression. The memory 
is gradually lost, the ideas become confused, and all reasoning power dis- 
appears. It becomes difficult to speak, in part from the required words being 
forgotten, and in part from loss of control over the organs of speech. The 
mental condition of the patient is but a few shades superior to that of the idiot. 
The paralysis gradually extends, the power of retaining the contents of the 
bladder and rectum disappears, the limbs waste away, and yet the force with 
which they are flexed is almost incredible, and thus the patient sinks, utterly 
unconscious of his own pitiable condition. In some cases, the flexure ceases 
and the limbs relax shortly before death. 

" Such are the ordinary symptoms of chronic softening. We occasionally, 
however, meet with cases in which extensive softening is revealed after death, 
but in which no perceptible symptom is appreciable during life ; and again, in 
which, some time previous to death, the symptoms have much abated. 

"Nothing very definite can be said regarding the duration of chronic soften- 
ing. I believe it may go on for years. Death takes place in various ways ; it 
is often dependent on the supervention of a more active head affection, and 
coma or convulsions close the scene ; meningitis may be developed, or there 
may be cerebral or meningeal hemorrhage, or an abundant effusion of serum 
into the ventricles or the subarachnoid space. Many patients finally sink from 
pneumonia, or in consequence of bad sores on the sacrum." 

"That there are often great difficulties in the diagnosis of cerebral softening, 
is a fact beyond all question ; it may be mistaken for inflammation of the brain, 
or of its membranes ; for congestion ; for cerebral or meningeal apoplexy ; or for 
morbid growths, or deposits in the brain. The diagnosis must be determined 
by the weighing of opposite probabilities. 

" Although the prognosis must always be most unfavourable, especially in the 
chronic form, there is undoubted evidence that the disease is occasionally cured. 
Cases sometimes occur, in which all the symptoms we have described gradually 
disappear, and where there is an almost perfect return of sensation, and of the 
power of the intellect, and of motion. 

"What are the causes of cerebral softening? No definite reply can be given 
to this question; but it is so often associated with arterial disease, (atheroma- 
tous and calcareous deposits in the smaller arteries of the brain,) and is, I be- 
lieve, so dependent on it, that the primary cause of the alteration in the struc- 
ture of the arteries may also be said to be the primary cause of cerebral 
softening. I look upon the disease as consisting essentially in a perverted or 
diminished nutrition, somewhat analogous to what occurs in senile gangrene._ 

"It only remains to speak of the treatment; having established our diagnosis 
to the best of our power, (for, I believe that a certain diagnosis is occasionally 
impossible,) all we can do (or, at least, do without increasing the risk of the 



1849.] Smith on the Principles and Practize of Obstetrics. 179 

patient), is to treat symptoms. When the disease commences with symptoms 
of congestion, purgatives, and the frequent application of leeches to the anus, 
constitute the safest treatment. A seton or issue in the back of the neck has 
been found serviceable in a more advanced stage. In the atonic form of the 
disease, we may do temporary good by mildly nourishing food and tonics. 

"The paralysis dependent on softening is never relieved by external appli- 
cations or by strychnine." 

We return our thanks to Dr. Day for his practical treatise on the domestic 
management, and most important diseases of advanced life. It cannot fail to 
prove a useful addition to the libraries of the student and practitioner. He 
has collected on these subjects much valuable matter. Some of the subjects 
treated of will demand a more extended investigation ; and to place at the com- 
mand of such, as may have the disposition and opportunity to complete what 
the author has so ably sketched out, the labours of those who have preceded 
him in the same field, he has appended a tolerably full bibliography. 

The object of the appendix is to assist in extending the use of a form of 
counter-irritation, which he has found of the greatest value in his own practice, 
and which is comparatively unknown to the great mass of the profession. It 
consists essentially in the instantaneous application of a flat iron button, gently 
heated in a spirit lamp, to the skin — an operation completed in a few seconds, 
productive of little or no pain, immediate in its effects, and altogether incapa- 
ble of injuring the patient. The cases given in illustration of the effects Of 
this means of counter-irritation, in lumbago and other forms of chronic rheu- 
matism, sciatica and other neuralgic affections, and certain forms of paralysis, 
will be read with interest. D. F. C. 



Art. XXIV. — Parturition, and the Principles and Practice of Obstetrics. By 
W. Tyler Smith, M. D., Lond. ; Lecturer on Obstetrics in the Hunterian 
School of Medicine. 12mo. pp. 395. Lea & Blanchard : 1849. 

The medical press has been so prolific, of late years, in works on the princi- 
ples and practice of obstetrics, that it seems difficult to conceive of the existence 
of any possible demand for a new publication on the same subject. Numerous, 
however, and excellent as are the obstetrical treatises that have appeared within 
a comparatively short period, we are still persuaded that the lectures of Dr. 
Smith will meet with a favourable reception, and, though they are not adapted 
to supersede the standard works already in our possession, they will, neverthe- 
less, be found an interesting and valuable addition to the library of the 
obstetrician. 

There is an originality in the manner in which the several subjects embraced 
in these lectures are treated. In his attempt to elucidate and establish the 
physiology of the uterus and its appendages, the author has laid the basis for a 
radical reform in the principles of obstetrics, that will banish much of the 
empiricism which has heretofore marked its practice, and aid, effectually, in 
elevating what has been too often regarded as an art to the rank of a science. 

The views advanced in these lectures, based upon the doctrine of the reflex 
action of the womb and its appendages, may not in every instance stand the test 
of future investigation. Some, we admit, bear the marks rather of hypothesis 
than of cautious deductions from well-established facts ; still, the work of Dr. 
Smith will, we are persuaded, have a beneficial tendency upon the principles 
and practice of obstetrics, by prompting renewed inquiry into the true 
physiology of parturition — correcting the mere mechanical notions that are 
prevalent in relation to the process, \>y the discovery of the laws which govern 
the actions of the uterus as a part of the living organism — the source from 
whence it derives its power, and by which it is prompted to act under 
its appropriate stimuli. 

The first, or introductory, lecture of Dr. Smith presents a comparison 
between British and continental obstetric medicine. It contains many just 
observations, and many to the correctness of which we cannot give our entire 



180 Bibliographical Notices. [July 

assent. There may be, generally speaking, too great a fondness for operative 
midwifery on the part of the continental accoucheurs, but we are convinced that 
the rules which govern them in the application of the forceps, even though it 
may lead to a too frequent application of these instruments, will still be found 
safer for both mother and child than those adopted by the generality of the 
British practitioners. The author has included American midwifery in his 
general censure of that of France. A reference to a correct series of obstetri- 
cal statistics would prove how little the censure on the accoucheurs of this 
country is merited. 

The second lecture treats of what the author denominates the three leading 
ideas which obstetricy, as it exists at the present time, reveals to us, with more 
or less distinctness, and around which many lesser ideas have ranged them- 
selves in the advance of this department of knowledge. 

These primary or leading ideas may be termed Development (of the embryo), 
Mechanism (of labour), and Motor action (of the uterus). " We may trace the 
idea of Development up to Harvey ; that of Mechanism to Chamberlen and 
Roonhuysen ; and the last idea — that which I have called Motor action — belongs 
preeminently, in its distinct form, to William Hunter." 

The lecture closes with a sketch of the progress of the nervi-motor physiology 
of parturition up to the present time. 

In the third lecture, are examined the different forms of motor action observed 
in human parturition — volition, emotion, reflex action, and peristaltic action, or 
contraction from the irritability of the uterine muscular fibre. 

" The phenomena of labour, and the great majority of the accidents and com- 
plications of childbirth and the puerperal period," are according to the 
lecturer, "nervi-motor; hence, a definite knowledge of motor action in general, 
and particularly of the uterus and its associated organs, is of the first import- 
ance to the scientific accoucheur." 

The subject of the fourth lecture is the nervi-motor action of the Fallopian 
tubes in menstruation, coitus, conception, and parturition ; and the nervi- 
motor actions of the vagina in the unimpregnated and parturient states; while, 
in the fifth lecture, are described the nerves of the uterine system, and the 
growth of the uterine nerves during utero-gestation. 

The whole of the subjects included in the first five lectures are treated of 
with great ability, and the author's exposition of them demands a close and can- 
did examination. A digest of the views presented would scarcely enable our 
readers fully to appreciate their value, nor would it give anything like a fair 
exposition of the manner in which the lecturer has presented and illustrated 
them. 

" Parturition," remarks Dr. Smith, " is not one reflex act, but a function, the 
combined result of many such actions, aided by other powers ; and we must 
study the preliminary phenomena, the different stages of the process, and the 
final accomplishment of the function ; when we shall find that Nature has at 
her disposal a wonderful succession of stimulus and action, exactly adapted to 
the dilatation of the os uteri and vagina, the propulsion and expulsion of the 
foetus ; and providing, also, for the safe contraction of the uterus, and its return 
to the unimpregnated state. 

" The uterus, as a motor organ, stands alone in many respects. Unlike the 
rectum and bladder, it is not directly influenced by volition ; and unlike the 
heart, it is extremely prone to reflex action ; it more nearly resembles the 
oesophagus, which is uninfluenced by the will, but it is endowed with reflex, 
motor, and peristaltic action. It, however, differs from the oesophagus in the 
great number of excitor surfaces with which the spinal system places it in 
relation ; neither is there any other organ — not even the stomach — which acts 
as a spinal excitor to so great a number of organs as the uterus and its excitor 
nerves, whether we consider it in the impregnated or in the unimpregnated 
states. Hence the physiological necessity for the abundance of nerves recently 
discovered. 

"Besides, the reflex action of the spinal marrow, and its system of excitor 
and motor nerves, there is the direct action of the spinal marrow — though this 
does not play the important part assigned to it by M. Serres, Brachet, and 



1849.] Smith on the Principles and Practice of Obstetrics. 181 

Segalas — in which the central organ meets its motor nerves, to the exclusion of 
the excitors, are involved. The state of the circulation affects all the motor 
organs under the control of the spinal marrow ; and they act with increased 
energy when the circulation is either plethoric or anaemic, though in the latter, 
exhaustion of the nervous energy quietly ensues. Thus, there is one puer- 
peral convulsion of hemorrhage, when the heart and blood-vessels have been 
drained of blood, and another of fullness of the circulation. Want and excess 
of blood, or materies morbi in the circulation, act as direct stimuli to the spinal 
centre, and thus the state of the circulation materially affects the uterus during 
labour. There are also certain agents of the materia medica which, taken 
into the circulation, affect the spinal marrow. Thus the ergot of rye, passing 
into. the blood, affects the uterus by a direct spinal action; so does strychnia; 
so does the inhalation of carbonic acid ; and so, I believe, does ipecacuanha, 
the influence of which, in producing uterine contraction, is very remarkable. 
Savine, aloes, alcohol, and the biborate of soda may probably be added to the 
same list." 

The remarks of the lecturer on the peristaltic or immediate action of the 
uterus are particularly interesting. 

In the sixth lecture, we have a beautiful exposition of the ovular or ovarian 
theory of menstruation. The analogy between menstruation, oestruation, and 
the oviposition of birds, insects, amphibia, and fishes, is examined, and the true 
nature of menstruation pointed out. The lecture closes with some judicious 
remarks on the diseases of menstruation, sterility, amenorrhoea, dysmenor- 
rhea, and ovarian convulsion, hysteria, and epilepsy. 

We present the views of the lecturer, in regard to the cause — so little hereto- 
fore understood — of dysmenorrhea. 

"In dysmenorrhoea, or painful menstruation, the greater portion of the 
pain consists, I am convinced, of ovarialgia ; the deep lumbar pain is decidedly 
ovarian, and not uterine. Many women suffer so much lumbar pain at each 
menstrual period, that it resembles, and, indeed, almost amounts to, a monthly 
attack of ovaritis. Almost all women in the better classes suffer so much pain 
and disturbance from menstruation, that we may almost venture to say men- 
struation, like parturition, lies in debatable ground, between physiology and 
pathology. Part of the pain of dysmenorrhoea, then, is ovarian, and that 
which is uterine, is often symptomatic of ovarian disorder. In dysmenorrhcea, 
there is doubtless a pathological state of the uterus induced ; but there would be 
no uterine excitement without the previous excitement of the ovaria. On the 
other hand, there are patients in whom the uterus is wanting, from congenital 
deficiency, who suffer all the ovarian pain of d3^smenorrhoea. Uterine dis- 
turbance must be considered as a secondary condition — an aggravated symptom 
of ovarian excitement in painful menstruation. Of one part of the uterine pain 
of dysmenorrhcea, I have a word to say — I mean that which women call the 
bearing down pain, and of which they complain so much, from the pubes down- 
ward to the knees. This bearing down I believe to be a tenesmus of the os and 
cervix uteri ; it is most frequent and severe in women who have borne children, 
and in whom the os and cervix have been developed. I have before directed 
attention to the points of similarity between the healthy actions of the various 
sphincteric muscles — you will find the pathological analogies equally interest- 
ing. The tenesmus uteri is analogous to the tenesmus of the bowel, or the 
tenesmus of the bladder. These spasmodic affections of the outlets of the sex- 
ual, urinary, and intestinal canals, are comparable with many other spasmodic 
symptoms. Thus the globus hystericus, or pharyngismus, is a contraction of 
tne pharynx, and the laryngismus affecting the larynx, and the form of cardi- 
algia dependent on contraction of the cardia, are analogous affections of the 
respiratory and digestive tubes. Of course, where there is disease of the os and 
cervix, the tenesmus uteri will be more distressing than usual, and will often 
require the chief part of our treatment ; yet the ovarian excitement in the back- 
ground must not be forgotten. I am decidedly opposed to the view that dys- 
menorrhoea is caused, in the majority of cases, by chronic inflammation of the 
os and cervix uteri. The relation between dysmenorrhoea and inflammation 
of the os uteri is generally one of coincidence, not of causation ; nay, it is 



182 Bibliographical Notices. [July 

often a symptom induced by ovarian irritation, a symptom requiring palliation, 
but the relief of which by no means constitutes the whole of our treatment. 
Let any one who believes in the merely uterine theory of dysmenorrhoea closely 
examine the nature and seat of the pain ; he will speedily be obliged to recog- 
nize the paramount influence of the ovaria. Of course, wherever there is in- 
flammatory action of the os and cervix, the inflammation will be rekindled at 
every menstrual period, and constitute a variety of painful menstruation ; what 
I am contending against is, the too exclusive attention of the practitioner to 
this superficial form of dysmenorrhoea." 

The seventh lecture treats of the principal motor phenomena of pregnancy. 
In connection with this subject, the lecturer offers what he believes to be an 
elucidation of the real nature of the movements generally considered to belong 
to the foetus. 

These movements he does not believe to belong to the foetus, but to be true 
peristaltic movements of the uterus. The reasons he offers for rejecting the 
generally received opinion in regard to their cause, must certainly be consi- 
dered as conclusive. The very idea of the foetus in utero producing them by 
any sudden change in its position, or by a sudden extension of its limbs, has 
long seemed to us so perfectly absurd, that we feel surprised to find any intel- 
ligent accoucheur of the present day continuing to sanction it; and when we 
come to examine into the circumstances under which the movements in ques- 
tion often occur, every one must be convinced of the impossibility of their 
being produced by muscular movements on the part of the foetus ; the expla- 
nation of the lecturer is highly plausible, and we are inclined to the opinion 
that it will be found, upon examination, to be the correct one. 

The subject of the next lecture is an inquiry into the cause of labour. After 
stating very fully the difficulties by which this inquiry is attended, the author 
proceeds to show, by a series of arguments, drawn from comparative physiology, 
that ovarian excitement is the law of parturition in all its forms of ovi-expul- 
sion. 

" There is," according to the lecturer, " a strict analogy between all the acts 
of the female generative organs — namely, coitus, cestruation, menstruation, 
conception, and parturition. Coitus and the sexual orgasm are merely incite- 
ments to the fruitful performance of the other acts of generation. The rest — 
cestruation, oviposition, menstruation, conception, and parturition — are only 
so many varieties of fertile or unfertile ovi-expulsion, and are convertible one 
into the other." 

"Parturition," the lecturer insists, "does not merely occur at what would 
otherwise be a menstrual period, but is essentially a menstrual period. 

"In menstruation, a small synergic and reflex arc is described between the 
ovaria and the Fallopian tubes; in parturition, a larger arc is in operation, 
extending from the ovaria to the uterus. At the time of ordinary menstruation, 
the ovarian irritation, which excites the contraction and rigidity of the Fallo- 
pian tubes, is manifest. Throughout utero-gestation, the ovarian excitement 
returns in a slight degree at each periodic date ; but at the eleventh period 
after conception (reckoning the last catamenial period inclusively), the ovarian 
excitement returns in full force, and, as a consequence, the uterine excitability, 
and the uterine actions of labour begin." 

In this lecture, Dr. Smith presents his objections to anaesthesia, as a means 
of suspending the pains of labour. He contends for the morality of pain, and 
insists upon the impropriety of etherization, independently of the risk attend- 
ing it, in consequence of the sexual orgasm under its use being substituted 
for the natural throes of parturition. 

The ninth lecture treats of abortion as a branch of spinal pathology ; we 
cannot enter upon a notice of the important ideas advanced by our author in 
relation to this subject. The causation of abortion, admitting the doctrine of 
the reflex character of the uterine actions to be correct, is cleared of many of the 
difficulties with which it is surrounded, by the views that are generally enter- 
tained in relation to it. 

The ensuing lecture on the prevention and treatment of abortion is replete 
with sound practical hints. 



1849.] Smith on the Principles and Practice of Obstetrics. 183 

The eleventh lecture describes the physiological stages of labour. The reader 
will be repaid for an attentive perusal of this lecture, by the novel and inte- 
resting views presented by the author, who has endeavoured to elevate the en- 
tire process of labour from a series of mere mechanical efforts, in which light 
it is even now too commonly viewed, to the rank of a succession of vital actions, 
having for their object the safe expulsion of the mature foetus. This sketch of 
the physiology of the pain of labour is highly interesting. 

The next lecture is devoted to a consideration of the subject of periodicity, 
in reference to the functions of the female reproductive organs. The views ad- 
vanced by our author in reference to it are original, and though purely hypo- 
thetical, have great plausibility. They must be carefully studied in order to 
be understood and appreciated. A general idea of the leading doctrine of the 
lecturer may be acquired from the following general summary : 

" The different organs of the reproductive system affect each other in a spe- 
cial and peculiar manner, in the causation of their periodic phenomena. The 
ovaria are the organs in which, during the continuance of the catamenia, the 
periodicities are most distinctly manifested, though these organs doubtless de- 
rive their periodic energies through the medium of the nervous system. We 
also know that the ovarian periodicity is specially modified by the condition of 
the breasts and the uterus. There is a remarkable synergic balance preserved 
between the three great organs of the sexual system — namely, the uterus, 
mammae, and ovaria. In the virgin state, the condition of the ovaria, at each 
ovarian periodic excitement, excites the uterus to secrete the catamenial flow. 
When impregnation has occurred, the changes set up in the uterus during the 
development of this organ and its contents, react on the ovaria, and interfere 
with the ovarian periodicities, so that they become masked during the whole 
term of pregnancy. At the time of parturition, the ovaria and uterus are the 
seat of a special excitement, and it is this excitement of the uterus and ovaria 
which excites the mammae to the secretion of milk for the supply of the new- 
born infant. After delivery, the uterus soon returns to a state of comparative 
repose ; but during lactation, the actions going on in the mammae, like those 
of the pregnant uterus in ordinary cases, prevent the full development of the 
ovarian periods. As soon, however, as lactation and the mammary develop- 
ment have ceased, the uterus, breasts, and ovaria, all resume their ordinary 
periodicity and evolution, and the catamenial flow proceeds regularly until a 
fresh impregnation occurs. Thus, the catamenial cycle of twenty-eight days 
is departed from at conception for another cycle — namely, that of gestation, 
which consists of two hundred and eighty days, or ten lesser cycles. After the 
completion of gestation, a new cycle is commenced — that of lactation — upon 
the completion of which the system returns to the simple catamenial cycle. 
These cyclical and epi-cyclical periods are themselves all included in another 
great period of development, extending from puberty to the decline of the cata- 
menia." 

The subjects of the thirteenth lecture are, the first extra-uterine phenomena 
of respiration, and the attendant changes in the foetal circulation. Keferring 
the first physiological act of respiration to the impression of the external air 
upon the excitor nerves of the surface of the body, and especially upon the 
trifacial, and pointing out the distinction between the regular reflex motor acts 
of respiration, and those which are of centric spinal origin, and are excited by 
certain changes induced in the medulla oblongata itself, by various causes, 
such as excessive abstraction of blood, or the circulation of venous blood only, 
in the spinal centre, the lecturer proceeds to a consideration of the causes of 
asphyxia neonatorum, and its treatment before and after birth. 

The views of the author are plausible, and his directions for the prevention 
and removal of asphyxia in the new-born child correct. 

In the fourteenth lecture are pointed out the applications of physiology to obste- 
tric pathology and therapeutics. Among the accidents and derangements of la- 
bour dependent upon excessive motor power, the lecturer arranges abortion, pre- 
cipitate labour, rigidity of the os uteri, rupture of the uterus, laceration of the 
perineum, &c. ; excessive after-pains, encysted placenta, inversion of the 
uterus, hourglass contraction, metastatic pains, and puerperal convulsions ; and 



184 Bibliographical Notices. [July 

among those dependent upon a defect of motor power, he classes uterine 
inertia, tardy labour, sinking, uterine hemorrhage, placenta praevia, retained 
placenta, and labour with paralysis. The relation of nervi-motor action to 
instrumental delivery, and manual operations, is pointed out, and the lecture 
closes with a new classification of obstetric therapeutics, &c. 

The ensuing lecture presents a view of the causes of excessive uterine action, 
and the means by which we can moderate or remove those unruly efforts of the 
uterus, and its associated organs, which become so dangerous in their results. 
The causes of excessive uterine action are, according to the lecturer, ovarian 
irritation, emotional disturbance, early rupture of the membranes, voluntary 
efforts, improper position of the patient, premature ossification of the foetal 
head, deformity of the pelvis, and particular presentations of the child, state 
of the circulation, and excessive digitation on the part of the accoucheur. The 
remedies for excessive action, enumerated by the lecturer, are the avoidance 
of physical and mental excitement, rest, laxatives, warm or opiate enemata, 
bleeding, nauseants, opium, abdominal bandage, &c. The remarks of the lec- 
turer on the causes and prevention of excessive uterine action are replete with 
good sense, and will be read with profit by the young obstetrician especially. 

The sixteenth lecture is on the cause and prevention of rupture of the uterus, 
and laceration of the perineum ; it is a highly interesting one. 

The seventeenth lecture treats of the causes and treatment of rigidity of the 
uteri, encysted placenta, inversion of the uterus, and after-pains. The views 
of the author upon these subjects will be found to be truthful, and his practical 
directions judicious. We present his account of the cause of inversion: — 

" From the best consideration I have been able to give the facts of inversion, 
I am persuaded that it depends in all cases mainly upon an active condition 
of the uterus. Where it takes place without any mechanical interference, there 
can be no doubt of the preternatural and perverted activity of the uterus. But 
I am convinced, that even in cases where the placenta is attached to the centre 
of the fundus, and when the cord is drawn through the vagina with any amount 
of force likely to be exerted by the accoucheur, it is not mere mechanical dis- 
placement which produces the accident ; but the irritation of the fundus uteri, 
by traction, excites contraction of the fundus, thus producing that contraction 
and descent of the fundus uteri, which is the first step of the accident. The 
common opinion has very naturally arisen, from observing, in some cases, that 
the fundus uteri, when the placenta is firmly attached, follows the advancing 
cord, while traction is being used. According to my view, the depression of 
the fundus uteri, even in these cases, is not a simple yielding of the part, ac- 
cording to mechanical principles, but an active contraction, excited by the 
irritation of the fundus uteri by the traction of the placenta. 

" To pursue the steps by which complete inversion is produced. There is 
first, cup-like depression of the fundus uteri ; coincident with, or immediately 
following upon this depression, there is hourglass contraction of the body or 
lower portion of the uterus. The annular contraction of the body of the uterus 
grasps the introcedent fundus as it would a foreign body, and carries it down- 
ward, for expulsion through the os uteri, the os uteri being at this time either in 
a state of inertia, or actively dilated, just as at the end of the second stage of 
labour. After the inverted uterus has passed through the dilated os uteri, this 
part of the organ becomes contracted, preventing reversion from taking place. 
Thus, there is, first, depression of the fundus uteri, with annular, or hour- 
glass contraction of the body of the uterus, and dilatation of the os uteri. Next, 
there is intussusception of the fundus by the body of the uterus. Lastly, 
complete inversion occurs, with contraction of the os uteri upon the inverted 
organ. The displacement may not be complete ; it may, in some cases, stop at 
introcession ; in others, at intussusception, and then return to the natural state; 
or it may remain intussuscepted." 

A very interesting lecture follows on certain extra-uterine reflex actions of 
an abnormal character, occurring before, during, and after parturition, as false- 
labour pains ; metastatic pains ; affections of the stomach, abdominal muscles, 
bladder, intestines, heart, larynx, &c. Rigors, diuresis, partial convulsive 
action, tympanitis, reflex counter-irritation, sensation of draught in the 



1849.] Smith on the Principles and Practice of Obstetrics. 185 

breasts. The lecture closes with some remarks on the motor actions of the 
mammae. We recommend an attentive perusal of this lecture ; the remarks of 
the author will be found to point to important practical results. 

The nineteenth lecture treats of the natural and morbid conditions of the reflex 
functions in the infant at the time of birth. The lecturer merely notices the 
morbus coerulaeus, which, he admits, can hardly be considered as a motor de- 
rangement. He refers it entirely to the persistence of the open state of the 
foramen ovale — a supposition which may be considered as being now entirely 
repudiated by a chain of most conclusive facts. Tetanus neonatorum is ex- 
plained by a reference to the reflex function of the spinal marrow: the spinal 
centre being excited by irritation of the umbilicus, or of the intestinal canal ; 
by the influence of temperature, particularly alternations of temperature ; by 
deficient ventilation, and want of cleanliness. The theory of Dr. Sims, that 
the disease is produced by pressure of the occipital bone upon the medulla 
oblongata, during and subsequent to parturition, in consequence of imperfect 
ossification and articulation of the cranium, is rejected. "Displacements and 
injuries of the cranial bones/ - ' the author remarks, "if they really do occur, 
must be as common in this country (England) as in America ; whereas, tetanus 
is extremely rare among us." But if, as Dr. Sims asserts, he has caused the 
convulsions immediately to cease by replacing the dislocated occipital bone, the 
objection of the lecturer falls to the ground. 

The all-important subject of puerperal convulsions is considered in the next four 
lectures. It would lead to a much greater extension of this notice than it was our 
intention to give to it, were we to enter upon an exposition of the author's 
views in relation to the pathology of this disease. He refers it entirely to irri- 
tation of the excito-motor portion of the spinal marrow, and considers the 
congestion and effusion in the brain as a consequence rather than as the cause 
of the convulsions. The opinions expressed in these lectures are replete with 
interest, and demand a serious consideration, being, as they certainly are, 
" capable of important practical application in the treatment and prevention of 
the disease." The author's remarks on the therapeutics of puerperal convul- 
sions should be carefully studied ; we believe that the principles laid down by 
him will explain some of the discrepancies in the experience of different prac- 
titioners as to the results of particular plans of treatment in this affection. 

The twenty-fourth lecture is on the causes and treatment of uterine inertia, 
while in the next two lectures, which complete the series, the management of 
uterine hemorrhage is considered at some length. 

The treatment laid down by the author does not differ essentially from that 
which would be pursued by every well instructed accoucheur. The merit 
claimed by him is not for the originating of any new plan for the management of 
uterine hemorrhage, but for the proper application, according to correct phy- 
siologico-therapeutical principles, of the remedies in common use, so as effect- 
ually to derive from them, in each case, the desired result — the arrest of the 
flow of blood. 

The lecturer concludes his exposition of the treatment of uterine hemorrhage 
with the following remarks : 

" The methods of obstetrication have been ample enough ; but the directions 
for their selection and combination have been very deficient. You have seen 
how susceptible all the remedies in this grave and important casualty are 
of physiological arrangement ; how, indeed, the mere touch of physiology has 
been sufficient to marshal them in something like due order and proportion. It 
would, I am sure, be impossible to find any subject within the entire range of 
medicine of equal importance, of which this might be said with more perfect truth. 

"Thus you see how profoundly physiology impresses itself upon our thera- 
peutics in the treatment of uterine hemorrhage. It will not do for those who 
are too idle to study the matter, to say : we will be practical — we will leave the 
physiology of the question to be decided by others. Physiology protests against 
being thus postponed; it will not be put off; for it is inseparable from practice. 
Without a physiological comprehension of the points of treatment, what is likely 
to happen ? In the arrest of hemorrhage, many remedies will probably be tried, 
either in succession, or in confused combination ; but instead of a judicious 



186 Bibliographical Notices. [July 

combination of the several modes by which uterine contraction may be pro- 
duced, mechanical means, or reflex or direct actions, will be trusted to alone, 
in such wise, that, though many remedies appear to be used, only one or two 
principles, and those, perhaps, not the most important, will be invoked. It is 
just like the old Mithridatic formulary ! Thus, suppose cold applied to the rectum, 
cold to the abdomen, iced water given the patient to drink, and the child placed 
at the breast, there is great appearance of activity, but in reality only the reflex 
action of the uterus has been excited, which would have been equally powerful 
if only one efficient mode of excitation had been tried. Or again, after one 
mode of reflex action had been tried in vain, the reflex function being exhausted, 
it would be only waste of time to endeavour to excite reflex action by applying 
irritation to other incident nerves ; yet this is often done. We do not use all 
the resources which physiology places at our command, unless we call forth, in 
a dangerous hemorrhage, the reflex spinal action, the direct spinal action, the 
irritability of the muscular fibre, and apply the mechanical methods of arresting 
the flow of blood from the uterus. If, for instance, instead of the jumble of 
reflex actions, we apply alternate heat and cold to the abdominal surface, give 
a dose of ergot, irritate the uterus through the abdominal parietes, and grasp it 
with the hands, we apply all the modes of inducing uterine contraction, and we 
thus get far more than a fourfold increase of contractile power." 

In the foregoing notice of Dr. Smith's Lectures, we have attempted nothing 
more than a brief sketch of their leading contents, and of the general doctrines 
upon which the lecturer bases his exposition of the cause and process of par- 
turition, and the leading principles and practice of obstetrics. The lectures 
are confined, strictly speaking, to the physiology, pathology, and therapeu- 
tics of the parturient and puerperal states. The anatomical, manual, and 
instrumental branches of obstetrics are passed over by the author without 
notice. Limited, however, as is the scope of the work before us, it is particu- 
larly rich in original views, judicious suggestions, and sound practical directions. 
We cannot, it is true, acknowledge the verity of all that the lectures contain in 
reference to the several subjects of which they treat, nor do we recognize the 
entire accuracy of all the deductions that are drawn from well established 
premises. The general principles, however, that are advocated by the author, 
and his application of these in explanation of the physiology of parturition and 
obstetrical pathology and therapeutics, are worthy of a close and careful study ; 
Dr. Smith has certainly done more than any writer who has preceded him, in 
elevating obstetrics to the rank of a science. D. F. C. 



Art. XXV. — Reports, for 1848, of Institutions for the Insane in the United States : 
1st. Of the McLean Asylum for the Insane, Somerville, Massachusetts. 
2d. The State Lunatic Hospital, Worcester, Massachusetts. 
3d. The Boston Lunatic Hospital, South Boston, Massachusetts. 
4th. The Butler Hospital for the Insane, Providence, Rhode Island. 
5th. The State Lunatic Asylum, Utica, New York. 
6th. The State Lunatic Asylum, Trenton, New Jersey. 
7th. The Pennsylvania Hospital for the Insane, near Philadelphia, Pa. 
8th. The Western Asylum, Staunton, Virginia. 
9th. The Hospital for the Insane, Indianapolis, Indiana. 

1st. From the report of Dr. Bell, we obtain the following risume' of the me- 
dical history of the McLean Asylum during the past year: — 

Patients in the asylum, beginning of the year 

" admitted during the year 
Whole number - 

Discharged - 
Remaining at the end of the year 



Males. 


Females. 


Total. 


93 


80 


173 


71 


72 


143 


164 


152 


316 


87 


48 


155 


77 


84 


161 



ales 


Females. 


Total. 


55 


37 


92* 


4 


10 


14 


4 


3 


7 


16 


9 


25 


15 


8 


23 



1849.] Insane Hospital Reports. 187 



Of those discharged, there recovered 
" "•" much improved 

" " improved 

" " unimproved 

died 

Causes of death. — Males — Old age 3, phthisis 2, paralysie ginirale 3, epilepsy 
6, general exhaustion 3. Females — Old age 2, general decay 3, phthisis 1, ery- 
sipelas 1, acute cerebral disease 1. 

From 1837 to 1848, both inclusive, the number of patients admitted was 
1696; discharged 1607 ; cured 884; died 184. 

"The only personal restraint (as the phrase is somewhat technically used), 
which has been employed during the year, has been the application, in two or 
three cases, of the most ingenious contrivance of the first physician of this 
asylum, Dr. Wyman — 'known as the bed-strap — in which an arrangement of 
webbing and buckles maintains the patient recumbent in bed, yet with liberty 
to change from side to side. 

"In certain extreme cases of puerperal and other exhaustive forms of mania, 
or where delusion compels a perpetual standing on the feet until utter exhaustion 
is endangered, the value — I might say the essential necessity — of this means, has 
been so often and strikingly verified, that I can hardly believe that any conscien- 
tious physician, however much wedded to the general theory of non-restraint, 
could decline its use, if he were acquainted with its efficiency and its gentleness. 
Such examples of disease, like all the rarer kinds of insane peculiarities, occur 
in institutions quite capriciously, by intervals of freedom being followed by 
repeated cases. 

"All other forms of mechanical restraint have been abandoned with us for a 
number of years, and with no reason thus far to regret their disuse. The ex- 
pense of doing justice to a household of insane patients, without the use of any 
confining measures, is certainly much augmented, unless the poor equivocation 
is resorted to, of getting rid of muscular restraints by the substitution of strong 
rooms. It would be absurd and hazardous for an institution, in which econo- 
mical considerations had to be strictly regarded, to aim at this ultimate refine- 
ment in the care of the insane ; that is, a real, and not merely a delusive, avoid- 
ance of personal restraints." 

The wing for the male patients at this asylum has been greatly improved, 
in its internal construction, during the year, and a system of hot water heating 
and exhaustive ventilation has been introduced. An account of these improve- 
ments occupies the remainder of the report. 

No man in the country has more thoroughly studied the subjects of heating 
and ventilation than Dr. Bell, and his recent address, before the Massachusetts 
Medical Society, upon " The Practical Methods of Ventilating Buildings," em- 
bodying the results of his researches and reflections, is a very valuable contri- 
bution to hygiene. 

2d. From the report of Dr. Chandler, of the Hospital at Worcester, we glean 
the subjoined statistics : 

Patients in hospital at beginning of year 
Admitted in the course of the year - 
Whole number - 

Discharged -.---- 
Remaining at the end of the year 
Of those discharged, there were recovered - 
" died 

* The report says " eighty tivo" but gives the number in each sex as follows, "fifty- 
five males,and thirty-seven females." In these details there are 161 discharged patients 
accounted for: whereas, it had just been stated that the number discharged was 155. 



Wales. 


Females. 


Total. 


207 


187 


394 


128 


133 


261 


335 


320 


655 


118 


128 


246 


217 


192 


409 


67 


69 


136 


15 


15 


30 



188 Bibliographical Notices. [July 

Causes of death. — Marasmus 7, apoplexy and palsy 5, epilepsy 2, consump- 
tion 3, disease of heart 1, disease of brain 1, typhus fever 1, lung fever 1, 
" dysenteric" fever 1, chronic dysentery 1, erysipelas 1, diarrhoea 3, exhaustion 3. 





Males. 


Females. 


Total. 


Patients admitted, from opening of hospital, 








1833 .... 


1555 


1529 


3084 


Discharged ----- 


1338 


1337 


2675 


Of whom were cured - 


688 


743 


1431 


died - - - - 


151 


121 


272 



The hospital has been more crowded with patients during the past year than 
at any previous time ; the number having been so great as to make it necessary 
for many to sleep upon beds placed, at night, upon the floors of the galleries. 
Dr. Chandler recommends the erection of another institution for the insane in 
Massachusetts, and, in the event that this should be effected, suggests the pro- 
priety of placing the male and the female patients of the State in separate 
asylums. 

"There are some advantages," says he, "which suggest themselves, in hav- 
ing the insane in an institution all of one sex, and few or no disadvantages. 

" Males can be supported in a hospital somewhat cheaper than females can. 
Their labour is more profitable, and they are satisfied with less attention of 
nurses. In this hospital, about fourteen dollars per annum is expended for 
attendants' care of each male patient, and about twenty-one dollars for each 
female. Females, too, require a larger carriage establishment. Probably, the 
expense of provision and clothing is somewhat larger for males than females." 

The following quotations are made from the comments upon the tabular sta- 
tistics. 

"Cases of palsy are almost sure to terminate fatally within three years. It 
is a disease almost peculiar to the male sex. It is very seldom that general 
paralysis is met with among females. The active man of business who has 
contracted habits of intemperance, is very liable to become paralytic. 

"Closely allied to palsy is a disease of the nervous system, resulting in con- 
vulsions of an epileptic character. The insane, who have epileptic fits or con- 
vulsions, seldom or never recover. They continue along many years, perhaps, 
but almost always becoming gradually more diseased, and more demented. 

"From these two classes of patients, much of our fatality proceeds. 

"Consumption and disease of the functions of nutrition, or marasmus, are 
very common in the last stages of fatal cases of insanity. 

"One boy, less than eight years old, was brought to us the past year. He 
was taken insane, soon after having a fever, before he was three years old. His 
mind has not expanded much. His case is a hopeless one. We thought his 
habits were improved by a few months residence under our care. But he will 
be a troublesome person to manage, for those who may have the care of him. 

" The insane appreciate their religious advantages here. They can discri- 
minate between what is wrong and what is right, unless it is upon the subject 
of their delusions. They as heartily repent of their transgressions, when made 
sensible of them, as any rational person. Many have a deep religious feeling, 
and a strict sense of justice. It is only when their delusions and ungovernable 
propensities intervene, that their thoughts and actions vary from that of others." 

3d. At the Boston Lunatic Hospital, the number of patients was as follows: 

Males. Females. Total. 

November 1st, 1847 - - - - 78 ' 78 156 

Admitted during the year - - - 37 69 86 

Whole number 115 127 242 

Discharged ----- 30 26 56 

Remaining, November 1st, 1848 - - 85 103 188 

Of those discharged, there were cured - 17 13 30 

" died - 7 8 15 

Causes of death. — Dysentery 4, general palsy 3, marasmus 2, disease of heart 



1849.] Insane Hospital Reports, 189 

1, suicide 1, exhaustion 1, consumption 1, chronic diarrhoea 1, pleuropneu- 
monia 1. 

In his comments upon the causes of the mental aberration of the patients 
received during the year, Dr. Stedman relates the following case : — 

"A phenomenon of rather singular character seems to have been the origin, 
at least the proximate cause of insanity in one of the patients. Her sister states 
that, about two years ago, when thirty-nine years of age, there suddenly sprang 
out upon her chin and upper lip a thick growth of beard ; that her spirits were 
much affected by the circumstance; that she became more and more unhappy 
and mortified by her strange appearance ; till at length she could not be persuaded 
to pursue her customary occupations. She was brought here laboring under 
the deepest depression and melancholy, from which she still suffers. Her beard 
continues to grow, and she is shaved with the regularity of our male patients. 
I have not been able to learn whether, at the time of this sprouting of the hair, 
the bodily health of this patient was peculiarly affected in any way." 

It is known that some physicians deprecate yards, courts, or enclosures for 
the patients of institutions for the insane ; and recommend, as substitutes, ve- 
randahs attached to the buildings. Upon this subject Dr. Stedman makes some 
sensible remarks, which we copy : — 

"We know the effect produced on the vegetable creation by the deprivation 
of light. The history of man is not without numerous illustrations of analo- 
gous evils inflicted on the human frame by a residence in dark and gloomy 
apartments. The benefits accruing to the insane by a change of air, and the 
enjoyment of the full sunlight, such as would be afforded them by leaving the 
halls of the house for spacious airing grounds, would be observed in their more 
healthful personal appearance, a more contented and cheerful disposition, a less 
irritated and irritating demeanor, as well as in many other ways. In short, no 
system of lighting, ventilating, or warming a building can be made to super- 
sede the necessity of granting to the insane the liberal use and enjoyment of 
the external air at all proper opportunities." 

4th. The Butler Hospital for the Insane, so named in commemoration of Mr. 
Cyrus Butler, who contributed forty thousand dollars to the fund raised for its 
establishment, is beautifully situated upon the westerly shore of the Pawtucket 
or Blackstone river, two miles, north-easterly, from the city of Providence. It 
was opened for the reception of patients on the 1st of December, 1847, under 
the superintendence of Dr. Isaac Ray, formerly superintendent of the Maine 
Insane Hospital, and distinguished for his admirable writings upon the medical 
jurisprudence of insanity. 

His first Report is before us. It embraces a period of thirteen months, end- 
ing December 31st, 1848. 

Jtfales. Females. Total. 



Patients admitted 


- 


84 


72 


156 


Discharged - - - - ' 


- 


28 


28 


56 


Remaining -.'.-'-- 


- 


56 


44 


100 


Of those discharged, there were cured 


- A 






17 


" " died 


- 






13 



Causes of death. — Consumption 5, apoplexy 1, general paralysis 1, delirium 
tremens 1, acute mania 3, chronic mania 1, cancer and old age 1. 

"Of the twenty-six cases discharged uncured, fifteen had been with us but 
three months, or less ; and of these, seven were regarded as curable, and would 
probably have recovered under a fair trial of treatment ; while their future con- 
dition, it is very likely, will be but a continued change from bad to worse. 

It would be impossible, of course, to penetrate into all the various motives that 
lead to such removals ; but a notice of the principal ones will sufficiently illus- 
trate how lightly people assume the responsibility of tampering with, and experi- 
menting upon so serious a thing as the mental derangement of a fellow-being. 
I refer to a childish impatience that cannot wait a reasonable time for the event 
of recovery, and never rest until some new method of treatment is adopted. 
They do not seem to be aware, nor are they willing to learn, that insanity is of 
No/XXXV.— July, 1849. 13 



190 Bibliographical Notices. [July 

much longer duration than most acute diseases, and that in many, if not most 
of the cases that finally recover, weeks and months pass away without any sen- 
sible improvement. This is a fact of so much importance that I run the hazard 
of saying what many may already know, by referring more particularly to the 
organic law with which it is connected. Fever, pneumonia, small-pox, measles, 
for instance, have a tolerably uniform duration, and we may predict, within a 
few days, the period when the result of the case will be apparent. Of some 
other diseases to which the body is liable, such as scrofula, dyspepsia, necrosis,. 
catarrh, we may confidently say that recovery, if it happens at all, is a very 
distant event. Such is the law of nature ; and the resources of art, however 
they may mitigate suffering, or change some of the accidents of the disease, 
cannot prevail against it. The duration of insanity, too, though far more va- 
rious than in the above instances, is governed by a law scarcely less inflexible. 
Though as curable as most severe diseases, yet the period within which recovery 
may occur, is much broader than that belonging to any other. According to 
observations, made by Esquirol, during a certain series of years at the Salpe'- 
tri€re, where the stay of the patient is determined by the will of the physician, 
— not the caprice of friends, — less than one-half of the recoveries were effected 
within the first year, and more than one-tenth subsequent to the second year. 
The average duration of the disease he estimates at one year. Very different 
is the ^'popular opinion ; and every day we are obliged to witness the disappoint- 
ment of hopes that have been entirely unwarranted by the laws of disease. As 
month after month passes away with but little improvement, the minds of 
friends are filled with perplexity and wonder at the obstinacy of the disease ; 
their confidence, in the propriety of the course they have taken, gradually ebbs 
away ; and new experiments are tried, for the purpose of hastening an event 
which nature chooses to delay. Accordingly, the patient is removed to his own 
home, or is placed with friends in the country, or goes upon a journey, or is 
subjected to some of the empiricisms of the day. No longer feeling the gentle 
restraints of the asylum, surrounded by those who are ever ready to gratify his 
wishes, and moving in a circle of influences that tend to renew the excitement 
and restlessness that had begun to subside under the tranquilizing effects of 
rest and seclusion, he rapidly loses whatever he may have gained. He is then 
returned to the hospital, to regain, by a tedious process, the ground he has lost ; 
or is kept at home, to be subjected to additional experiments, and to sink, at 
last, into a state of incurable disease. I have known many experiments of this 
kind — that of attempting to find some shorter road to recovery — but my obser- 
vations have furnished me with scarcely a single instance of success." 

The subjoined extract is encouraging to the advocates of non-restraint in the 
management of the insane. 

"Believing that in this institution no merely economical considerations should 
prevent us from adopting any improvement intimately connected with the highest 
interests of the insane, we have, from the outset, been governed by the rule, 
that mechanical restraint should be considered as an extreme measure, to be 
used only when the object in view was clearly beyond the reach of any other 
means. Biassed by no theory, and controlled by no will but our own, we have 
endeavoured to observe this rule faithfully and honestly ; and the result is that, 
during the thirteen months we have been in operation, having one hundred and 
fifty-six patients under our charge, we have used mechanical restraint in one 
instance only. This was to prevent a person from tearing open a wound, and 
was continued for three or four days. It is a fair question to ask, whether this 
result has not been obtained by the sacrifice of considerations more or less im- 
portant ; for, after all, this must determine its practical value. My reply is, 
that I have no reason to believe that, in a single instance, has the comfort of 
the patient been compromised, nor that seclusion has been carried further than 
it otherwise would. The destruction of clothing might have been considerably 
lessened, no doubt, by the more liberal use of restraint, but it is impossible to 
say, with any degree of certainty, to what extent." 

The paramount utility of asylums over jails, and similar places of confinement. 
as receptacles for patients suffering under mental alienation, is illustrated by 
the case subjoined. 



1849.] Insane Hospital Reports. 191 

"We received one of this class of persons, who had been confined for eleven 
years. During all this time, constituting so large a share of the period allotted 
to man, he never left his cell except to pass into an adjacent one; he had never 
placed his foot upon the ground, nor breathed the air of heaven except through 
grated windows. One may faintly conceive, but language cannot describe, the 
luxury of the sensations which thrilled through every nerve and muscle in his 
body, as he paced our galleries, and once more walked abroad, with nothing 
between him and the open sky above and the solid earth beneath. After staying 
with us about nine months he was discharged ; and from that day till this, he 
has been earning an honest livelihood by working on a railroad. " Had this per- 
son committed any crime of unparalleled atrocity, that he should have been 
subjected to a punishment which for duration and severity is unequalled by a 
single penalty in the statute-book ? Far from it ; he had committed no criminal 
act whatever ; he was only insane." 

5th. By the report of Dr. Brigham, of the New York State Asylum, it appears 
that the number of patients at that institution were : — 

Males. 
December 1st, 1847, 231 

Admitted during the year - 201 

Whole number - - - - 432 

Discharged - - - - - 189 

Remaining, November 30th, 1848, - - 241 

Of those discharged, there were cured - 87 

Died ------ 46 

Causes of death. — Dysentery 35, diarrhoea 10, marasmus 12, meningitis 10 T 
epilepsy 5, general paralysis 5, consumption 3, suicide 2, old age 1, apoplexy 1, 
gangrene of leg 1, hydro thorax 1. 

The unusual number of deaths is sufficiently explained by the following ac- 
count of a severe form of dysentery which prevailed at the asylum in the months 
of August and September. 

" During these two months a large number of the patients, and a considerable 
number of the attendants and assistants, were affected by dysentery or diarrhoea. 
195 patients — viz. 80 men and 115 women — were attacked by dysentery, and 27 
men and 18 women by diarrhoea, making a total number of 240 cases. Of this 
number 39 died, viz. 35 of dysentery and 4 of diarrhoea. 

" The above, however, does not include 21 cases of dysentery and 9 of diar- 
rhoea that occurred among the attendants and assistants, none of which proved 
fatal. The disease prevailed about the same time in all parts of the building, 
and alike affected those that had previously been out of doors most of the time, 
and those that had not been out at all. It also prevailed in most of the towns 
in this region, and proved fatal to many, especially to those whose systems were 
impaired by previous disease. At this asylum, with the exception of two cases, 
all that died were patients who had either been long insane, or whose bodily 
health was previously very poor, and of whose restoration to reason we indulged 
no hope." 

From the mass of matter in this valuable report, we select such extracts, and 
collect such facts, as are most interesting or important. 



smales. 


Total 


241 


472 


204 


405 


445 


877 


193 


382 


254 


495 


87 


174 


40 


86 





Males. 


Females. 


Total. 


Patients admitted from Jan. 16th, 1843, to 








Dec. 1st, 1848, - 


1017 


997 


2014 


Discharged ----- 


776 


743 


1519 


Cured - 






814 


Died 






200 



Of the 2014 patients, 108 men and 143 women, a total of 251, were disposed 
to suicide. 

"It is often said that a person will not commit suicide if placed in a room 
with others. This is, we presume, generally correct, but not always, as some 
have not only attempted suicide, but actually accomplished it under such cir- 



192 Biblwgraphical Notices. [July 

cumstances ; though, so far as we have personal knowledge, they have committed 
the act while the others were sleeping, or else secreted themselves from ob- 
servation behind curtains, or other objects. Thus, we have known it effected 
by hanging, and without noise, while others were in the same room. Hence 
the necessity of unceasing vigilance in cases where the disposition to suicide is 
known or suspected." 

The number of suicides during the past four years in the State of New York, 
so far as could be learned, was, in 1845, 74 ; 1846, 64 ; 1847, 106 ; 1848, 88. 

Of the 2014 patients received at the asylum, 637 were known to have insane 
relatives. 

Known to have insane parents, men 121, women 152 : total 273. 

" Of the 121 men, the number having insane fathers, was 64 

mothers, " 53 

" Of the 152 women, the number having insane fathers, " 67 

mothers, " 80 

"And four men and five women inherited a predisposition to insanity from 
both parents. 

" Thus it would appear from our inquiries, and they have been very carefully 
conducted, that insanity is a little more likely to be transmitted by the mother 
than by the father, and that mothers are considerably more likely to transmit 
it to daughters, than to sons ; while the fathers most frequently transmit it to 
sons. 

" Liberty, so favourable to the development of the human intellect, multiplies 
the causes of its derangement. Hence, in countries where there is most intelli- 
gence and freedom, there will be found the greatest mental activity, and the 
most cases of insanity. We are of the opinion, and it is an opinion formed after 
much inquiry, that there is more insanity in this country, especially in the 
northern and eastern States, than in any other ; and that it is fearfully on the 
increase. 

" In our opinion, the most frequent and immediate cause of insanity, and one 
of the most important to guard against, is the toant of sleep. So rarely do we 
see a recent case of insanity, that is not preceded by a want of sleep, that we 
regard it as almost the sure precursor of mental derangement. 

" Notwithstanding strong hereditary predisposition, ill health, loss of kindred 
or property, insanity rarely results unless the exciting causes are such as to 
occasion loss of sleep. A mother loses her only child, the merchant his fortune ; 
the politician, the scholar, the enthusiast, may have their minds powerfully 
excited and disturbed ; yet if they sleep well they will not become insane. 

" We shall be pardoned for respectfully mentioning our apprehension that the 
study of insanity is too much neglected by physicians engaged in general prac- 
tice. We have no hesitation in saying that if the physicians of the country 
were fully aware of the importance of this subject, and would as thoroughly 
study insanity as they do other diseases, and exert themselves to prevent, by 
timely advice, and to arrest it in its early stage, they would do those predis- 
posed to insanity, and the insane themselves, an amount of good unequalled by 
that of the asylums of the country." 

In a general description of the medical treatment pursued at the asylum, we 
find the following remarks. 

"Many of the patients sent to this institution have been injured by too much 
bleeding and depletion before they were committed to our care. Some we think 
have been rendered incurable by this treatment, and we cannot forbear remark- 
ing, that, in our opinion, the work of Dr. Rush, on the ' Diseases of the Mind/ 
in which directions are given to bleed copiously in maniacal excitement, has 
done much harm, and, we fear, it is still exercising a bad influence ; and we 
hope no future edition will be issued without notes appended, to correct the 
errors into which the distinguished author has fallen, for want of the numerous 
facts which have been furnished since his time, and which enable us to see the 
errors of our predecessors." 

Dr. Brigham has used stramonium, as recommended by Dr. Moreau, of Tours, 



1849.] Insane Hospital Reports. 193 

in cases of hallucinations of vision and audition, but has observed no material 
or permanent benefit from it. He has " employed electro-magnetism in many 
cases, without any other good effect than that occasioned by the amusement or in- 
terest created by the use of it." He has administered the hashish to a consider- 
able number, but, " on none had it any lasting effect either good or bad." He 
has used ether, by inhalation of the vapour, "to a large number, both men and 
women, who were affected with various forms of mental delusion," and, he re- 
marks, " to none has it proved injurious, and we are rather favourably impressed 
with its use,though we do not expect any striking remedial effects from it." 

The effects of chloroform were found very similar to those of ether. Neither 
of them was administered in cases of recent insanity, nor, in those having the 
form of mania with high excitement. 

" Cod-liver oil we have used in many cases, and think with benefit in some 
instances. We apprehend it will be found a useful remedy in certain cases of 
insanity, accompanied by emaciation and costiveness, and when there is a ten- 
dency to consumption or rheumatism." 

6th. The New Jersey State Lunatic Asylum is about two miles north-west of 
the city of Trenton. Its situation combines many advantages of convenience, 
utility, and beauty. In its internal construction, it is said to display all the im- 
provements suggested by experience in both Europe and America. 

It was opened for the admission of patients, on the 15th of May, 1848, under 
the superintendence of Dr. H. A. Buttolph, who, for three years, was associated 
with Dr. Brigham in the asylum at Utica. 

The first annual report embraces a period of but seven and a half months, 
ending Dec. 31st, 1848. 

During that period the patients received were 
Discharged cured -■-,-- 
Remaining at the end of the year 

The report is written with ability, and affords evidence that the author is 
acquainted with the business to which he has been called. Being intended, 
however, for a community of readers to whom the subject is comparatively new, 
it does not, and it could not be expected that it would, contain anything particu- 
larly novel to those who have for many years read the reports of other similar 
establishments. 

7th. During the past year the Pennsylvania Hospital for the Insane, has been 
most of the time occupied by patients to the full extent of its accommodations. 

Number at beginning of the year - 188 

Admitted in course " " - 215 

Whole number " " - - - 403 

Discharged in course of the year - - 203 

Remaining at close - - ' - - - 200 

Of those discharged, there were cured - - - 120 

" died ---. 17 

Causes of death. — Exhaustion following acute mania 5, chronic disease of 
brain 3, pulmonary consumption 2, congestion of lungs 1, old age 1, effects of 
accidental fall 1, prostration, incident to long-continued excitement and a re- 
fusal of food, 1. 

In his remarks upon the premature removal of patients from the hospital, 
Dr. Kirkbride informs us that, "as early as 1754, the Managers of the Pennsyl- 
vania Hospital resolved to admit no insane person who was not allowed to re- 
main twelve months in the house, if not cured sooner, or deemed by the physi- 
cian incurable." 

Such should, if possible, be one of the rules of every institution for the in- 
sane. The number of cures would then undoubtedly be from thirty to forty 
per cent, greater than under existing circumstances. 



Males. 


Females. 


Total. 


47 


39 


86 


1 


2 


3 


46 


37 


83 



Males. 


Females. 


Total. 


773 


611 


1391 


671 


520 


1191 


357 


276 


633 


74 


56 


130 



194 Bibliographical Notices. [July 



Patients admitted since opening of the hospital 

Discharged and died - 

Discharged cured - 

Died ..... 

A building 40 feet by 26, and one story high, was erected during the past 
year, at the distance of 186 feet west of the central portion of the main edifice 
of the hospital. It is occupied as a museum and reading-room for the patients, 
and is furnished with minerals, shells, and other objects of science and curiosity, 
as well as with newspapers, periodicals, and engravings. Such a place of re- 
sort is of eminent value in the moral treatment of the inmates of the institution. 

"The annual course of lectures has been repeated, and with results quite as 
satisfactory as detailed in previous reports. A full audience, respectful atten- 
tion, correct deportment, and an obvious interest in the subjects discussed, have 
been almost invariably observed, and no one who has watched the progress of 
this part of the system of treatment can doubt that good effects have resulted 
from it. 

"In no branch of treatment for the insane," says Dr. K., "is there greater 
room for progress, nor one in which important results are more likely hereafter 
to be attained, than in that which is directly mental in its character. It is not 
in the early period of the disease that it is so essential, but after the acute stage 
has passed — where the malady appears disposed to assume a chronic form, or 
even where individuals seem to have reached that point at which they are too apt 
to be styled hopeless ; and where neglect and ill treatment are sure soon to make 
them so. It is, indeed, to the mentally lowest class of patients in our hospitals, 
that attention should be most steadily directed ; it is among these that will yet 
be found the widest sphere for benevolent labor, and from which results will 
occasionally flow, that will reward any one who engages in the work in the true 
spirit of perseverance, and without faltering, because the field is less promising 
than some others. It has always been an object in this hospital, as far as pos- 
sible, steadily to increase the means of direct mental treatment for all the pa- 
tients, but especially for those who reside in the lower wards. 

"The reading aloud to patients, often to a class few of whom ever take a 
book in hand, has been attended with the most satisfactory results. No more 
beautiful change has been effected in an entire class of patients, than is to be 
witnessed in both our lodges at certain hours, during which the teachers are 
reading to the assembled companies. On these occasions, there are rarely more 
than three or four, often only one or two absent, out of twenty of what is styled 
the worst class of patients ; and the conduct of all present, and the attention 
given to the reading, has on many occasions been truly surprising. These 
hours seem to be looked forward to with the proper feeling by many, and the 
visits of the teachers are evidently a source of pleasure to the patients gene- 
rally. The good effects of this kind of reading are also obvious, in the other 
wards, in which it is pursued regularly ; but it is in the lodges that they have 
been most striking. Some months since, as one of the means of still further 
testing the influence of provision for more extended means of amusement, in- 
struction, and occupation for the class of patients under notice, a piano — not 
so good as we could desire, but the only one then available — was placed in one 
division of the lodge for females. I hazard little in saying that no instrument 
in the institution has been more used within the last few months, has given 
more pleasure, or been more useful to those who have used or listened to it. 
Ladies whose minds appeared lost — who had not seen an instrument of the kind 
for many a long year, and who were supposed utterly incapable of using one — 
were found to be gradually attracted to it, and, by practice, seemed to be car- 
ried back in some faint degree to the feelings and tastes of other days ; and, 
thus employed, have been calm, when ordinarily they were excited, and have 
aven been able to impart no little pleasure to those around them." 

8th. Dr. Stribling, of the Western Asylum, Virginia, has lived to see his in- 
fant institution — infantile in size, if not in age — grow to the goodly stature of a 
man, and, unfortunately, now about to assume the unwieldly dimensions of a 



Females. 


Total. 


86 


207 


31 


70 


117 


277 


30 


72 


87 


205 


19 


40 


6 


22 



1849.] Insane Hospital Reports. 195 

giant. He informs us, in this report, that when the additional buildings al- 
ready commenced shall have been completed, there will be accommodations for 
more than four hundred patients. Its capacity will then equal that of the hos- 
pital at Worcester, Mass., and be exceeded in this country by the asylum at 
Utica alone. 

Males. 

Patients at commencement of year - 121 
Admitted during the year - 39 

Whole number - - - - 160 

Patients discharged during the year - 42 

remaining at end of year - - 818 

Of those discharged, there were cured - 21 

died - - 16 

Causes of death. — Marasmus 10, cerebral congestion 3, phthisis pulmonalis 1, 
chronic diarrhoea 1, exhaustion and old age 1, epilepsy 1, chronic aphthge 1, 
hydrothorax 1, dysentery 1, cerebritis 1, dyspepsia 1. 

The following remarks by Dr. Stribling, illustrate the experience of every 
physician charged with the management of a public institution for the insane. 
We copy them in the hope of contributing to the dissemination of truth, and the 
lessening of the evil complained of. 

" There is one other topic upon which it may be well here to say a word, as 
it too frequently happens, notwithstanding our efforts to correct the evil, that 
our difficulties are greatly enhanced, and the comfort of the patient materially 
impaired by his being decoyed, as it were, to the asylum ; discovering, only after 
his arrival in the neighborhood, that he is the victim of deception. The friends 
of the insane, influenced by a natural affection, and averse to witnessing the 
effects of coercion upon them, console themselves with the reflection that, after 
they reach the asylum, should they be unwilling to remain, there are appliances 
to compel submission without subjecting the unfortunate individual to public 
exposure, whilst sheriffs and other officers too frequently resort to stratagem in 
order to save themselves trouble. Could all be made sensible of the mischievous 
effects of such a course upon the afflicted individual after he enters the asylum, 
we can but think they would willingly undergo the sacrifice of feeling, or bear 
with the trouble which a different course might impose. One of the effects 
most to be deplored is, that the individual having been betrayed by those whom 
he had known longest and had much confided in, becomes, of course, suspi- 
cious of the officers of the institution, who are strangers to him, and hence, our 
influence is greatly impaired. 

"In addition to this, many patients reason themselves into the belief, that, as 
they were brought to the asylum by treachery, they have a moral right to resort 
to artifice to effect their escape ; and consequently, unless kept as prisoners, 
closely confined to their apartments, or subjected to the constant supervision of 
an attendant, they succeed, causing trouble and expense to the institution, and 
often protracted and painful anxiety to their friends. We can but repeat the 
advice heretofore tendered, that all patients/ whatever the character or degree 
of their insanity, be frankly apprised, by those having charge of them, toliy they 
are to be removed from home, and where they are to be placed ; and, in the event 
that they resist, that any degree of force, which the case may call for, be resorted 
to rather than evasion or deception !•" 

9th. Dr. John Evans, the former superintendent elect of the Hospital for the 
Insane in Indiana, resigned the office about a year since, and Dr. R. J. Patterson, 
for some time senior assistant physician in the Ohio State Asylum, was appoint- 
ed as his successor. 

The report before us was issued in October last. At that time apartments 
for the accommodation of about fifty patients were completed, and it was ex- 
pected that the institution would be opened in the course of the following 
month. 

The buildings, when finished internally, will furnish apartments for two hun- 
dred patients. Dr. Patterson thinks it will soon be fully occupied, as he had 
already received more than fifty applications. P. E. 



196 Bibliographical Notices. [July 



Art. XXVI. — An Account of some of the most important Diseases of Women. By 
Robert Gooch, M. D., with Illustrations. Second edition. Philadelphia : 
Ed. Barrington and Geo. D. Haswell, 1849. 8vo. pp. 322. 

A Practical Compendium of Midwifery ; being the Course of Lectures on Midwifery, 
and on the Diseases of Women and Infants, delivered at St. Bartholomew's 
Hospital, by the late Kobert Gooch, M. D. Prepared for publication by 
George Skinner, M.E. C. S. Fourth American edition. Philadelphia: Ed. 
Barrington and Geo. D. Haswell, 1849. 8vo. pp. 339. 

We regard the publication of these works with pleasure, as affording evidence 
that the profession are not content to depend for knowledge on the compen- 
diums and text-books, prepared to facilitate the progress of the student, but are 
disposed to seek for information at its original sources. It may be well for the 
young student, before he is competent to form a judgment, to rely upon the 
digests prepared for his guidance ; but the advanced student, and the practi- 
tioner who wishes to be something more than a mere routinist, must consult 
the great masters of our science, study their opinions in their own writings, 
compare their views, and form his own opinions. Among these great masters 
Robert Gooch will always stand pre-eminent, and the profession are under ob- 
ligations to the publishers for placing his works within their reach. 



Art. XXVII. — Ancesthesia, or the Employment of Chloroform and Ether in Sur- 
gery, Midwifery, &c. By J. Y. Simpson, M.D., F.R.S.E., Professor of Mid- 
wifery in the University of Edinburgh, &c. Philadelphia : Lindsay & Blakis- 
ton, 1849. 8vo. pp. 248. 

This work comprises the substance of several essays written at different times 
by Prof. Simpson, and published in the Monthly Journal of Medicine, and of 
the verbal statements of his experience in the use of anaesthetic agents, made 
to some of the medical societies of Edinburgh, and reported in their proceed- 
ings. These are now first collected in a volume by the author, and form a very 
interesting history of anaesthetic agents, coloured somewhat of course by the 
zeal of the author, who is well known as the introducer of chloroform as an 
anaesthetic agent, and the enthusiastic and able advocate for its employment. 

The author has not confined himself to his own experience, which is very 
extensive, but has collected much valuable information from the practice of 
various public hospitals ; and his volume embodies much valuable and interest- 
ing information on the subject which should be carefully weighed by every 
practitioner of medicine. 



1849.] 197 



QUARTERLY SUMMARY 

OF THE 

IMPROVEMENTS AND DISCOVERIES 

Itf THE 

MEDICAL SCIENCES. 

ANATOMY AND PHYSIOLOGY. 

1. On tlie Development and Functions of the Spermatozoa. By Drs. Wagner 
and Leuckardt. — The elaborate inquiries of the authors into the constitution 
of the seminal fluid of different animals, have led them to some new and valu- 
able results, which tend to modify in several particulars the opinions formerly 
entertained. The account which they now give of the origin of the sperma- 
tozoa is as follows : 1. All spermatozoa originate in "formative vesicles," which 
appear to resemble the secreting cells of glands, in being metamorphosed epi- 
thelium-cells of the glandular tubuli or follicles. 2. From these formative 
vesicles, the spermatozoa are produced in one of the three following modes : 
a, by the conversion of the cell-membrane and nucleus of the formative vesicle 
itself into the spermatozoon, a method in which the change is the least possible, 
and which is only found among the Nematoid worms ; b, by the metamorphosis 
of the nucleus of the formative vesicle into the spermatozoon, a method which 
is much more common, especially among the lower animals, in many of which 
(as Chilopoda, Acarina, and Entomostraca) the spermatozoa remain as solid 
massive corpuscles, resembling the nuclei from which they sprang, instead of 
having the filiform shape of ordinary spermatozoa ; c, by the endogenous deve- 
lopment of cells originating in the nucleus of the parent cavity, each young 
cell producing a spermatozoon within it. This last method is that which we 
find in all the higher animals ; but its latter part may take place in two ways. 
The parent vesicle may burst and set free the young cells, before the latter 
have begun to form the spermatozoa, which then evidently issue from them. 
But it frequently happens that the development of the spermatozoa takes place, 
whilst the cells within which they are formed are yet within the parent vesicle ; 
and the walls of these cells give way, so that the spermatozoa come to be asso- 
ciated together in bundles within the parent-cells, as formerly described by 
Wagner, and are finally set free by their rupture. 

> The authors have come to the conclusion that the spermatozoa are the essen- 
tial constituents of the semen; having met with cases in which the liquor 
seminis is altogether absent ; and being also greatly influenced by the apparent 
impossibility of the fertilization of ova by liquor seminis, when there is no 
copulation, and the semen is diffused through water, as in most fishes. — Cyclop. 
ofAnat. and Phys., Part xxxiv. 

2. HassaVs Parasite. — In the Zeitschrift, Bd. vii. Heft 3, Henle corrects an 
erroneous statement of Hassall, who has described a peculiar kind of corpuscle 
found in coagulated fibrin of the heart as a parasite, and of an animal nature, 
Henle refers to the description of this given in the second volume of his 
" Eandbuch der Bationellen Pat7iologie." 



198 Progress of the Medical Sciences. [July 

Hassall states, that the corpuscles are of the size of colourless blood corpus- 
cles, or even three or four times larger, and of an irregular form, which gene- 
rally approaches the circular, and that they consist of a nucleus, of irregular 
shape, and of a number of concentric membranes. Acids, and especially the 
sulphuric, greatly assist their discovery. Hassall incorrectly ascribes their 
discovery to Gulliver ; but the description and drawings of this author, in his 
translation of " Gerben's Algemeine Anatomie," only treat of colourless blood 
corpuscles, with many nuclei, and anucleate, collapsed corpuscles, which were 
probably clods of fibrin. Hassall adds, in a note, that he has found these con- 
centric corpuscles in a thymus gland which had lain many hours in water. 

Lately, Henle has often found corpuscles to which (some optical illusions 
apart) Hassall' s statement would completely apply, in an effusion which seemed 
to come from the glands of the larynx. This effusion contained, together with 
pus corpuscles, groups of large granule cells, containing fat and some pigment; 
and he thus had the opportunity of satisfying himself ihat these concentric 
bodies are formed by molecules of fat included in the granule cells. They are 
most numerous and complete when the granule cells are digested in acetic acid, 
after having laid for a day or two in distilled water. Under these circumstances, 
the fat within the cells runs together into large drops, or it breaks out and 
unites itself into small or large masses, which often adhere to the cells. These 
masses are mostly round, clear, and colourless ; but they are rendered very 
distinct by lines which take a course parallel to their contour. These drops do 
not contain a nucleus, but the shifting of the focus causes their centre to become 
darker or clearer than their circumference, and thus gives a false appearance 
of one. In like manner, the concentric striae are purely an optical phenomenon, 
depending on the refractile powers of the fat ; so that the same corpuscle, in 
different situations as regards the focus, appears now simple and pale, now 
striated and dark. Fresh granule cells, treated with acetic acid, give rise to 
the same appearances, save that the'striae are usually fewer in number ; and 
these are, also, no doubt identical with the concentric corpuscles of Hassall. 
The presence of an acid is not essential to their production. 

A figure in a previous volume of the Zeitschrift, to which Henle refers, 
quite corroborates this view. And we may add, that, besides the internal evi- 
dence of accuracy which his statement bears, there are, perhaps, few micro- 
scopists that have not, at one period or other, been deceived by bodies of this 
kind, for a longer or shorter space of time. — Med. Times, May 26, 1849. 

3. Structure of the Papillce of the Tongue. — Mr. Hassall states that a minute 
and careful examination of the papillae of the tongue has convinced him that 
the term conical, as applied to certain papillae of that organ, is a misnomer, 
and that these are excavated and cupped in form. 

Corresponding with this general shape of the papillae, and determined by it, 
is the arrangement of the secondary papillse, of a number of which each com- 
pound papillae is made up in a circle, the boundary of which corresponds with 
the raised margin of each cup. 

The vessels and nerves supplying these papillae of course follow a similar 
circular distribution. 

In the recent state, and while the epithelium still remains attached to the 
subjacent structures, it is not easy to make out the true form of these cupped 
papillae, in consequence of the number of filiform processes which are attached 
to them, obscuring it ; near the front of the tongue, however, and where these 
filamentary processes are either entirely absent or very short, the cupped form 
may be very readily determined, even while the epithelium is still adherent. 

It is worthy of remark, that the processes in question, which are constituted 
of epithelium, follow the same circular arrangement which appertains to the 
papillae and loops of blood-vessels and nerves ; and also that they spring from 
the raised margins of the cups. 

These observations are both interesting and important, because they disprove 
the opinion entertained by many physiologists and microscopists, that the fili- 
form papillae of the tongue have merely a mechanical office to perform, and that 
they are not concerned in any degree in the sense of taste ; the form and arrange- 



1849.] Organic Chemistry. 199 

ment of the several parts of each papillae showing an evident adaptation to the 
reception of gustatory impressions. 

The filiform appendages entangle and delay the smaller particles of the food, 
and the cavities of the papillae receive the nutritious juices, and retain it for a 
time sufficiently long to produce the necessary impression on the sensory 
papillae by which each cup is encircled. 

Considered altogether, it would be difficult to imagine or devise an arrange- 
ment of parts more admirably adapted to the purpose to be fulfilled. — Lancet, 
March 1849. 

4. On the Minute Structure and Mode of Contraction of Voluntary Muscular 
Fibre. By W. Murray Dobie, Esq. — The first part of the author's paper con- 
tains a short statement of the various discoveries which have been made in the 
minute structure of voluntary muscle. The last author referred to is Mr. 
Bowman, who has described the ultimate fibrilla of muscle as composed of clear 
and dark spaces, arranged alternately in longitudinal series. The author then 
refers to the descriptions taken by various writers from the specimens of mus- 
cular fibre prepared by Lealand, a London optician. These specimens show 
the ultimate fibrilla to consist of clear, oblong, rectangular spaces, bounded by 
a distinct line, and joined end to end. In the centre of each there is a small, 
dark, oblong space, between which and the peripheral line of the clear space, 
there is a clear interval. From his observations on the muscles of all classes of 
animals, the author considers that the structure of muscle is still more complex 
than has yet been described. He finds an ultimate fibrilla to consist of quadri- 
lateral spaces, which are of two kinds — the dark and the clear ; these alternate 
regularly, and are arranged in single longitudinal series. 

The dark and the clear spaces are sometimes equal in length — more frequently 
the latter are the shortest, and in the lobster and salmon appear sometimes as 
a mere line. When the fibre is stretched, the clear space is elongated and 
flattened, while the dark space appears somewhat elevated. These spaces are 
bounded laterally by a distinct line, which appears continuous ; they are also 
separated from each other by distinct lines. 

The clear space is crossed transversely at right angles by a dark line, which 
divides it into two equal quadrilateral spaces. The dark space is similarly divided 
by a clear line. Each space, therefore, consists of two compartments, which 
are similar in every respect to each other. Such is the appearance presented 
when the centre of the fibrilla is in perfect focus. When the surface is brought 
into focus, the light space appears dark, and does not show a cross line ; while 
the dark one appears light, and shows the cross line dark, and more decided 
than before. The author has further found that, when the fibrillae are sepa- 
rated, a delicate homogeneous membrane stretches from one to the other. This 
membrane is quite distinct from, and much more delicate than, the sarcolemma. 
In the skate it is striated, the striae corresponding to those seen on the fibrillae: 
this appearance is attributed to the membrane being more elevated or thicker 
opposite the dark spaces. 

The author has made some observations on the contraction of muscular fibre, 
as it is seen to take place in the tail of the tadpole, when the animal is placed 
uninjured under the microscope. On contraction taking place, the transverse 
striae are seen to approach rapidly, and to recede as rapidly on relaxation. 
The blood is driven from the part by the contraction of the muscle, but again 
returns on relaxation taking place. 

Mr. Dobie concludes his paper with some directions as to the mode of prepar- 
ing specimens. — Monthly Retrospect, from Annals of Nat. Hist., Feb. 1848. 



ORGANIC CHEMISTRY. 

5. Chemical Pathology of Diarrhoea. — Oesterlin, in Henle and Pfeujfer's 
Zietschrift, Bd. VII. Heft 3, contributes an important paper on the Chemistry 
of Diarrhoea, a disorder which is exceedingly prevalent in the Baltic provinces, 
especially in conjunction with ague and malaria disorders. 



200 Progress of the Medical Sciences. [July 

The older chemical schools attributed extraordinary appearances to the 
excrements, bile, and blood of the dysenteric, but valid'researches have not yet 
been made ; so that this disease, which offers most to the chemist, has perhaps 
been most neglected by him. And in pursuance of these pathological errors, 
therapeutic singularities have obtained. Diarrhoea has been treated with 
mercurials, since the bile is supposed to act some mysterious part in the 
tragedy ; or patients already purged ten and twenty times in the hour, have 
been treated with laxatives, on account of an alleged dependence of tenesmus 
on accumulation of feces. It was only a few years ago that Masselot, and 
Follet, for the first time analyzed the blood in this disease ; and their analyses, 
grouping many cases together, will allow little stress to be laid on the results. 

Many 'circumstances had for fifteen years drawn the author's attention to the 
evacuations in these diseases, especially in the cases seen in the Baltic 
epidemic of the autumn, 1846. Their appearance, the blood they contain, their 
physical properties, and their enormous quantity in the twenty-four hours, all 
indicate them as an important element of the disease. So, likewise, the often 
rapid collapse, the rapid wasting (especially of the face), and the manner in 
which persons previously in robust health are completely prostrated, all these 
circumstances, which are unexplained by anatomical alterations in the intest- 
inal canal, point to the statement, that the materials set free from the body 
greatly preponderate over those taken into it, and that this preponderance 
occurs with a rapidity and intensity differing only in degree from Asiatic 
cholera. But though the dependence of the two sets of facts be apparently 
obvious enough, yet he had never seen any experiments upon either the 
composition or quantity of the evacuations. After long delay, a favorable 
opportunity presented itself in the following cases : — 

The three first were of diarrhoea ; the last was the diarrhoea occurring in the 
latter stage of Bright's disease. They seem to have been severe, but not 
extraordinary cases, and the examinations were not made in the earliest and 
most acute stage. The first and last terminated fatally ; the others completely 
recovered. The analyses were conducted with the assistance of Dr. C. 
Schmidt. The method of examination, in most instances, included the urine ; 
but the small quantity of this, and, in all but the taste, its healthy character, 
precluded any error of consequence. 

In the four cases, on an average, the quantity of evacuation in the twenty- 
four hours, amounted to 2433 cubic centimetres, or to 721 cubic inches English. 

The average of nine examinations gave the daily loss of albumen 50§- 
grammes, or 782| grains English. The albumen was (a) albumen of serum (b) 
epithelial structure ; on an average of three comparisons, the latter amounted 
to one-sixth of the former variety. 

On an average of eight examinations, the quantity of fixed salts thus 
removed in the twenty-four hours was 14J grammes, or 224f grains English. 

The author compares the large quantity of albumen thus obtained with two 
other cases ; one the flux produced by calomel and jalap, in a case of chronic 
disease of the brain; the other, the (loose ?) stools of a typhoid patient. In the 
diarrhoea, the albumen amounted, in the average of eight examinations, to 
24.75 parts in the thousand ; in the two latter instances, to about 3 J parts per 
thousand, the two being nearly alike, 3.3 and 3.9. This is scarcely a seventh 
of the preceding quantity. 

Comparing the composition of the stools with that of the blood, from which 
they must be derived, the following points are noticeable : — 

The quantity of albumen in the whole blood-mass may be estimated at 800 or 
900 grammes — about 29J oz. English. Thus, in less than three weeks, such a 
daily loss as the estimate above would equal the whole quantity normally 
present. Or, daily, a seventeenth of the whole quantity is removed. Again, 
taking the quantity of fixed salts present in the blood as about one-tenth of the 
albumen, the daily loss may be estimated at l-170th of the whole quantity in 
the blood. 

The absolute daily loss of albumen fluctuated considerably ; but the per centage 
of albumen present, or its number of parts in the thousand of evacuations, had 
a very constant and well-marked relation to the severity and date of the 
disorder ; subsiding as it subsided, or aggravated on its relapse. 



1849.] Organic Chemistry. 201 

Some blood taken by cupping was examined in two instances. In both the 
quantity of water was increased, the quantity of salts was nearly normal, while 
the remaining constituents had decreased. The impoverished blood had been 
able to replace the water lost, while the organic constituents were still missing. 

The author goes on to apply these chemical results, to explain the condition 
of the different organs and functions. The small anaemic pulse, the sunken 
eye, the small quantity of urine, the condition of the secretions generally, are 
all referred to in turn. But our readers will have heard or read most of these 
before. We have, therefore, only to add, that he appears inclined to regard 
diarrhoea as essentially a chemical process, manifested by the tendency to 
thickening of the mucous membrane, and exudation from it. To this we can 
only say, that on like grounds we must call all secretion, both healthy and 
morbid, a chemical process. This we must hesitate to do. Yet, until we can 
state why the healthy intestine secretes healthy intestinal mucus, we cannot 
tell why the diseased one should separate its diseased product, however 
different in appearance and quality the latter may be. — Med. Times, May 19, 
1849. 

6. On the Source of Sugar in the Animal Economy. By Dr. Bernard.— Sugar 
is extensively distributed throughout the vegetable kingdom, but it exists also 
in animals. Vegetables do not find it ready made in the earth, but form it by 
some power of internal organization. Is it the same with animals? or is the 
sugar found in their bodies exclusively the product of their vegetable ingesta? 
This is the important question which it is our intention to submit to the test of 
experiment. 

Sugar enters largely into the composition of the food of animals. The kinds 
of sugar are, — 1st. Cane sugar, such as is found in the sugar-cane, beet-root, 
carrots, &c. 2d. Grape sugar, such as exists in grapes, and other saccharine 
fruits. Fecula should also be considered as saccharine matter, inasmuch as it 
is convertible into low sugar during the process of digestion. 3d. Sugar of 
milk, which is found in the milk of animals. 

This is not the place to trace the distinctive characters of these forms of 
sugar, nor to determine the alternate changes which they undergo in order to 
become subservient to nutrition. I need only state, that as certain alimentary 
substances are known to furnish considerable quantities of sugar, we may con- 
sider them as the source of the saccharine matter which we discover in the 
blood, or other animal fluids. It is admitted that sugar is to be found in the 
healthy blood, after the ingestion of sugar, or matters convertible into sugar. 
But chemical facts teach us, on the one hand, that starch is the only principle 
which is convertible into sugar ; and, on the other hand, in the belief that the 
animal economy has not the power to originate a principle, but only to trans- 
form those which are presented by the vegetable kingdom, it has been denied 
that the animal organism can form sugar, and the only power recognized is 
that of destroying and eliminating it. The facts which will be developed in 
the following essay, show us that such an opinion is not warranted by phy- 
siology. 

First Series of Experiments. — It has been observed, that during the di- 
gestion of saccharine or amylaceous matter, the blood contains sugar, and it 
has thence been concluded that the sugar is furnished by the aliments. The 
result of experiment taken alone is exact ; but the experiment itself is incom- 
plete, and the conclusions therefore false, as will be seen. 

1st Exp. I injected thirty grains of starch, dissolved in a pint of water, into 
the stomach of a rabbit which had eaten oats and carrots. Five hours after, 
the animal was destroyed in the usual way, and thirty grains of blood from the 
heart collected. After coagulation, sugar was distinctly found in the serum. 
The stomach and intestines contained sugar, arising from the carrots and the 
transformation of the farina. 

2d Exp. A strong dog was destroyed five hours after eating 300 grains of 
the jelly of starch. The serum of the blood taken from the heart contained a 
notable quantity of sugar. The contents of the stomach were acid, and con- 
tainoil no sugar; those of the intestines were alkaline and strongly saccharine. 



202 Progress of the Medical Sciences. [July 

3d Exp. A dog ate plentifully of sheep's head, and was killed after seven 
hours. In the serum of the blood sugar was distinctly found. No sugar was., 
found in the intestinal canal. 

4th Exp. A dog was killed after fasting two days. Sugar was unequivocally 
found in the serum. 

The above experiments were repeated several times, and always with the 
same results. The general fact established is readily seen, viz., that sugar is 
constantly present in the blood of animals, whatever has been the nature of 
their food. 

Second Series. — Whence is the sugar derived in the case of the animals fed 
on meat, and in that which had not eaten for two days previous to death ? This 
is the question for the solution of which fresh experiments are required. It 
may be fairly presumed that the sugar was not formed in the heart, but had 
been transported thither from some other parts of the body. To determine 
more exactly the locality of its formation, I performed the following experi- 
ments. 

1st Exp. A large, strong dog being killed, seven hours after a hearty meal of 
cooked meat and bones, digestion was found to be in full operation, and the 
gastro-intestinal circulation, and chyliferous ducts fully distended with their 
respective contents. I obtained, 1st, some blood from the junction of the 
splenic vein with the vena portae ; 2d, some chyle from the thoracic duct ; 3d, 
blood as before from the cavities of the heart. I then carefully separated the 
contents of the stomach and bowels, and tested each separately for sugar with 
the subjoined results: — 

1. The alimentary matters of the stomach and small intestines had an acid 
reaction, and afforded no evidence of the presence of sugar. 

2. The milky serum afforded by the coagulation of the chyle was also desti- 
tute of sugar. 

3. The blood of the vena portse being allowed to coagulate, the serum was 
slightly opalescent and alkaline. I distinctly ascertained the presence of a 
large quantity of sugar. 

4. The blood from the heart also presented sugar, but in less abundance. 
The experiment was repeated several times, and with always the same result, 

but without my being able to comprehend how the portal blood should contain 
so large a quantity of sugar, while none existed in the small intestines. Ke- 
flecting, however, that this matter must be derived from some neighbouring 
viscus, I proceeded as follows : — 

Having quickly destroyed a dog which had, some hours since, fed on matters 
destitute of sugar or fecula, I opened the abdominal cavity, and placed liga- 
tures, 1st, on the branches of the mesenteric veins, close to the small intestines ; 
2d, on the splenic veins, close to the spleen; 3d, on the pancreatic vein; 4th, 
on the trunk of the vena portso as it entered the liver. I then collected blood 
from each of these sources, and examined it. 1. Sugar was not found in the 
blood of the intestines, nor in their contents. [The original states that sugar 
was found, but this is evidently an error of the press, as appears from the con- 
text. — Trans.] 2. Sugar was not present in the blood, either of the splenic or 
pancreatic veins. 3. The blood of the portal veins contained a large quantitj 7 " 
of sugar, as did also the tissue of the liver itself. 

It was thus made evident that the liver was the source of the saccharine 
matter. But it must be asked, how is it that sugar is found in the portal veins ; 
for supposing it to be formed in the hepatic glandules, it should be carried into 
the general circulation by the hepatic veins, and not flow back into the portal 
branches. This reflux is, in my opinion, easy to be understood ; for, in fact, 
the circulation in the porta is mainly effected by the pressure of the abdominal 
parietes during life ; if, therefore, the pressure be removed as in opening the 
abdomen, there would immediately be a reflux from the absence of valves in 
the portal system. 

We have ascertained, by the above experiments, that sugar is found in the 
liver, and is carried into the general circulation by the blood of the hepatic 
veins, the reflux into the porta being accidental ; but we regard this discovery 
to be so important, that we think it right to state the processes employed ip. the 



1849.] Materia Medica and Pharmacy. 203 

investigation, in order that others may confirm, or confute, our conclusions, by 
following in our footsteps. 

Tests for Sugar in the Liver itself. — A portion of liver is to "be "beaten 
in a mortar, and then boiled in a small quantity of water, and filtered. The 
filtered liquid possesses all the properties of a saccharine fluid. It becomes 
darker on boiling with liquor potassse, and it reduces the double tartrate of 
potass and copper. If yeast be added at a certain temperature, fermenta- 
tion ensues ; if the fluid be distilled after fermentation, alcohol may be ob- 
tained. 

The attempt was made to procure sugar in substance by operating on large 
quantities of liver, but although a fluid of syrupy consistence was obtained, 
crystallization did not take place. 

The recognition of sugar in the blood is a very simple affair. The blood is 
allowed to coagulate, and the serum placed in a tube furnished with a stopper ; 
to this is added a sixteenth in bulk of the tartrate of copper and potash, and 
boiled, when a quantity of the salt is reduced, proportionate to that of the 
sugar present. By this process the smallest traces of saccharine matter may 
be detected. Both in this test, as well as that by fermentation, it is necessary 
to operate on the serum while it is fresh, as sugar is rapidly decomposed spon- 
taneously. 

We have now traced the sugar of animals to the liver, but we have further 
to determine whence it is derived. Two suppositions may be entertained ; 
either it results directly from a transformation of certain elements of the liver, 
or it is derived from the food. It may be said, in fact, that the animals which 
had been fed exclusively on animal food, or starved, might have eaten fecula 
or saccharine food the few days previously, and that the sugar thence derived 
had accumulated and been detained in the liver ; and it might be added in sup- 
port of this view, that the liver is known to retain arsenic and other poisons for 
a length of time. Without actually denying this view, the following experi- 
ments would seem to oppose it : — 

1st Exp. A full-grown dog was starved for eight days, and then fed abun- 
dantly on cooked meat for eleven days ; after this he was destroyed. The blood 
contained an abundance of sugar. This experiment was repeated several 
times ; and certainly it would appear probable, that sugar, derived from food 
given antecedently, would have been eliminated after a lapse of nineteen days. 

2d Exp. A rabbit, after a meal of carrots, was subjected to the division of 
the pneumo-gastric nerves. He was found dead seventeen hours after. No 
sugar was found in the blood or liver. This experiment was repeated with simi- 
lar results. In both animals the bile, which is generally alkaline, was found 
to have a distinctly acid reaction. 

This effect of division of the pneumo-gastric nerves is remarkable. As a 
further proof that sugar is found independently of food, I may state that I 
have found it in large quantity in foetal calves. 

From the above facts the author draws the following conclusions : — 

1. That diabetic sugar is a normal ingredient in the blood and liver of ani- 
mals. 

2. That the formation of sugar takes place in the liver, and independently 
of saccharine or feculent food. 

3. That this formation of sugar commences before birth. 

4. That it is allied to a state of integrity of the pneumo-gastric nerves. — 
Prov. Med. and Surg. Journ., Feb. 7, from Archives Q6n4rales de Med. 



MATERIA MEDICA AND PHARMACY. 

7. On Sugar as an Antiplirodisiac. By M. Provencal. — Camphor has 
hitherto, by reason of its prompt effects, been considered as the best antiphro- 
disiac, and as the best antidote to cantharides. But sugar is a far more powerful 
and useful remedy, diminishing the venereal ardour, and repairing, in some 
degree as an aliment, the melancholy effects of over-indulgence. The dose is a 



204 Progress of the Medical Sciences. [July 

pound or more, daily, in a quart of water, wine, or milk, according to the nature 
of the case. In the case of general irritability, as observed in members of the 
religious fraternity, and in priapism, it is best given in cold water. When 
excitement of the genital organs is complicated with irritation of the chest, 
milk is the best vehicle. — Brit, and For. Med. Chir. Eev., from Rev. Med.-Chir., 
torn. v. 

8. Physiological Action of Nitrate of Potassa. — By F. Loffler. — The follow- 
ing account of the action of nitre, is derived from a series of experiments made 
by five students on their own persons, while in health. The salt was taken in 
solution, with the addition of a little mucilage, in quantities increasing gra- 
dually from one to five drachms daily. The proportion for each day was divided 
into five separate doses. Each student took in this manner, during the course 
of one experiment, from three to five ounces. 

After from eight to twelve days' use of the medicine, the blood drawn from 
the veins presented the following characters: 1. In colour and density it re- 
sembled cherry juice. 2. The number and size of the colourless blood corpus- 
cles were increased. 3. The blood globules were paler in colour. 4. The 
blood coagulated very quickly. (The average time required for the coagulation 
of blood taken from the five subjects of experiment, previous to the employment 
of the nitre, was ten minutes — after its use, only five minutes and three quar- 
ters.) 5. Increased proportion of water, and corresponding diminution of the 
solid constituents of the blood. 6. Diminution of its fat. 7. Increased proportion 
of ash in serum. 8. Diminished firmness and elasticity of the crassamentum, 
the solid constituents of which were less in quantity than in normal blood. 

The symptoms observed from the use of the nitre were general weakness, and 
indisposition to exertion of body or mind, increasing in intensity with the con- 
tinued employment of the drug ; low spirits ; fatigue from the slightest exertion : 
the muscles and joints felt as if they had been bruised, and the knees were 
especially weak; constant disposition to sleep, slow and weak pulse. This 
last symptom began to show itself on the second or third day, and gradually 
became more marked ; so that towards the end of the experiment the frequency 
of the pulse was several times reduced to twenty beats in the minute. The 
pulse did not recover its normal strength and frequency for seven or eight days 
after the discontinuance of the medicine. Towards the end of the experiment, 
the face became distinctly paler and thinner. The appetite continued good, and 
the digestion was not disordered. The action of the bowels was for the most 
part healthy, at other times the drug occasioned some pain of the belly, followed 
by purging. On account of the great heat which prevailed while the experi- 
ments were made, no certain deductions can be drawn in reference to its action 
upon the kidneys. The quantity of urine, on several occasions, exceeded by as 
much again the amount of fluid drank, and generally there was more or less 
diuresis. 

The author promises to repeat his experiments when the temperature is more 
suitable, to ascertain precisely the changes induced in the composition and 
quantity of the urine. — Schmidt's Jahrb., 1848. 

[In the Union Med., of March 3, M. Vanoye reports a case, where one and a-half 
ounces of the nitrate of potassa were given, by mistake, to a young female, ill of 
typhus fever. For an hour she experienced considerable uneasiness and inclina- 
tion to vomit. Her face became remarkably pale, contrasting strongly with its 
previous febrile flush. Kepeated vomitings, alternated with fainting, soon suc- 
ceeded. The vomited matter contained bile, and a large quantity of blood. She 
complained of acute pains in the epigastrium. From being strong and full, the 
pulse was now small and irregular, and fears were entertained for the patient's 
life. She recovered. The treatment consisted in cold emollient drinks, a little 
laudanum, and sinapisms. She had no desire to urinate until about four hours 
after taking the nitre, when she passed some clear, high-coloured urine, which 
gave no deposit on cooling. Afterwards the quantity of urine was not greater 
than the normal. It is worthy of remark that, on the day folloAving, the pa- 
tient was convalescent from the typhus fever. This fact is the more surprising 
as, of three members of the same family who had typhus at the same time, one 
died, and the other two were long and seriously ill* 



1849.] Materia Medica and Pharmacy. 205 

M. Vanoye's case is peculiar in the entire absence of diuresis, which can be 
accounted for only by supposing that the salt was rejected by vomiting. The 
action being purely local on the gastro-intestinal mucous membrane, absorp- 
tion was prevented, and hence the secondary effects could not be manifested.] 
— Monthly Retrospect, April 1849. 

9. Experiments on Senna and Argol Leaves. — According to Heberleln - , spirit 
of wine extracts from senna leaves only chlorophylle and extractive matter, 
the cathartine of Lassaigne and Feneulle, which does not, however, possess in 
the slightest degree the purgative effect ascribed to it by these gentlemen ; for 
after repeated experiments with smaller quantities, the alcoholic extract of one 
and a-half ounces of senna leaves were taken without any effect. The useless- 
ness of treating senna leaves with spirit of wine, and the inefficacy of tinctura 
sennse are therefore obvious. The aqueous extract of four drachms of senna 
leaves, which had first been exhausted by spirit of wine, effected evacuations 
with griping : so that the griping principle had not been removed by the spirit. 
The leaves used for these experiments were those of Tripoli senna, which are 
quite free from the leaves of Cynanchum Argheul. The latter, which are found 
among the Alexandrian senna, are in bad favour among physicians, but without 
just grounds, for experiments made with the picked leaves of Cynanchum 
Arghuel showed them to be harmless. An infusion of two and a-half drachms 
produced no effect or inconvenience. — Monthly Retrospect, April 1849, from 
Pharmaceutisches Central-Blatt, No. 54. 

10. Sulphate of Amorphous Quinine. — As a therapeutic agent, Mr. Bullock, 
of London, considers this preparation in every respect equal, and for some pur- 
poses superior, to the crystalline variety of quinine. It is now some years 
since Mr. B. first recommended it to the profession, during which period its 
value as a substitute for the ordinary sulphate has been most extensively tested 
in all those diseases in which quinine is employed. As a periodic in intermit- 
tent fever and neuralgia, it appears to be equally energetic with the crystalline 
preparation, and as a stomachic and general tonic, many bear testimony to its 
greater efficiency, from the ease with which it is borne by the stomach. The 
headache, and other unpleasant effects, which frequently result from the exhi- 
bition of quinine, are rarely occasioned by the amorphous salt. 

The salts of amorphous quinine being deliquescent, the sulphate is sold in 
solution, five minims of which contain a grain of the salt. This is very con- 
venient in prescribing. Mr. B. recommends those who desire to employ it in 
combination with a vegetable acid, to order the acetate which is prepared in 
the same manner as the sulphate. The following are the proportions of the 
different acids required for the preparation of the salts of amorphous quinine, 

One grain of amorphous quinine requires 

4 minims dilute sulphuric acid. 

3 " hydrochloric acid. 

5 " nitric acid. 

3 " phosphoric acid. 

7 acetic acid. 

2 grains citric acid \ Mix with the amorphous quinine, 

2 " tartaric acid j then add a few drops of water. 

Hub the amorphous quinine with the aci.d in a mortar until it is dissolved. 

The price of the sulphate of amorphous quinine, which is less than one-half 
that of the crystalline variety, strongly recommends it to the physicians of 
hospitals, dispensaries, and other charitable establishments, as well as to 
country practitioners, who will find it a considerable economy. 

[From extensive trials, we are satisfied that the solution of the sulphate of 
amorphous quinine, represents all the most important physiological and thera- 
peutic properties of cinchona bark. We found it eminently useful in improving 
digestion, and in restoring the normal tone to the stomach of convalescents 
from cholera. In diseases of debility generally, it is an excellent tonic. Equally 
No. XXXV.— July, 1849. 14 



206 Progress of the Medical Sciences. [July 

active with the crystalline sulphate, it is certainly less apt to disorder the 
stomach in full doses. — Monthly Retrospect, April 1849. 

11. On the Employment of Nitrate of Silver as a Vesicant. ByM. Delvaux. 
— The general action of nitrate of silver on the tissues, seems to be to separate 
the hydrogen. When this salt is brought in contact with an organic body, it 
becomes decomposed into nitric acid, oxygen, and metallic silver, in a molecular 
state. Silver is deposited, and this imparts to the tissue its coloration, whilst 
the oxygen of the oxide of silver and of the decomposed nitric acid takes up 
the hydrogen to form water. 

When nitrate of silver is brought in contact with the skin, the effect produced 
varies according to the greater or smaller quantity of salt employed. If the 
quantity be small, it merely acts on the epidermic cells, which it disorganizes. 
Metallic silver is reduced to a molecular state, and combines with their ele- 
ments ; the epidermic tissue assumes a blackish brown coloration, owing to 
the metallic silver itself, and after a time the tissue is detached and drops. 
Where the action of the nitrate of silver is continued for a longer period of time, 
the true skin itself becomes affected, the effect produced varying according to 
whether the disorganization is merely on the surface, or more deeply seated. 
In the former case, an abundant serosity raises the altered epidermic surface, 
-and produces vesication. In the latter, the true skin, being disorganized in its 
thickness, produces an eschar. 

If now, we consider that the skin varies in thickness and sensibility in dif- 
ferent parts of the body, and according to age, sex, &c, it will be evident that a 
certain tact is required to regulate the quantity of nitrate of silver necessary to 
disorganize the epidermic layers, and procure a vesicatory effect without disor- 
ganizing the true skin. The principles by which the employment of escharo- 
tics in general is guided will suffice to prevent the occurrence of any unexpected 
results. 

Without proceeding to enumerate all the diseases in which vesication by 
means of nitrate of silver may produce beneficial therapeutic effects, we will 
adduce a few cases in refutation of the objections that might be advanced 
against this form of application. 

1. M. Claes, a patient in the hospital of des Viellards, who was recovering 
from an attack of adynamic pleuro-pneumonia with parotitis, complained, on 
the 3d of September 1848, of severe pain in the left sub-scapular region, and in 
the lateral portion of the neck, along the trapezius muscle. The pains increased 
on the least movement. Exposure to a current of air had given origin to this 
rheumatic affection. The skin was cauterized in the sub-scapular region with 
a stick of nitrate of silver, moistened with water at the moment of its application. 
A bulla appeared in the course of an hour and a-half ; epidermis being removed, 
a slight degree of suppuration was established, and the pain entirely ceased, 
as if by magic, at the end of about ten hours. 

The cauterized spot had been dressed immediately after cauterization with 
cold cream, and this was continued until the occurrence of cicatrization, which 
took place within the fourth day. 

2. A man named Boufort,came to consult M. Uytterboeven, at the same hos- 
pital. The old man had suffered since the preceding evening from acute stitch 
in the side. The pains extended along the seventh rib towards the back. As 
auscultation did not reveal anything abnormal in the thoracic organs, the spot 
to which the patient referred the pain was cauterized with nitrate of silver, pre- 
viously moistened with water. The pain disappeared as the operation advanced. 
A vesicle was produced in the course of an hour. A compress with cerate was 
applied to the wound. On the following day the pleurodynia was perfectly 
cured without the treatment being further continued. 

3. The same method was immediately employed in the case of Marie Demat- 
tre, who had been attacked by pleurodynia in the left side of the thorax. 
The pain was so violent as to call forth loud cries from the patient. The cure 
was equally prompt and unexpected, and in the course of the day the pain en- 
tirely disappeared. The vesication was treated in the manner usually adopted 
in the case of ordinary vesicants. 



1849.] Medical Pathology and Therapeutics. 207 

It only remains to add a word or two on the mode of operation of this vesicant. 
In order to avoid all chance of irregularity, it is necessary to rub the whole sur- 
face on which vesication is to be induced, lightly but equally with the point of the 
stick moistened with a drop of water, and to continue long enough until a gray 
coloration is produced. This effect is generally obtained in the course of a 
minute and a-half. If a deeper action be required, owing to the thickness of 
the epidermis, or a more strongly marked therapeutic effect be sought, the ope- 
ration must be repeated over the same surface and with the same precautions. 

M. V. Uytterhoeven has always found this vesicant answer his expectations 
most fully, both in private practice and in the wards of the hospital des Vieil- 
lards. — Monthly Retrospect, June 1849, from Nbuvettiste Medicate Beige. 

12. The Mechanical Leech of MM. Alexandre & Co. of Paris. — This appara- 
tus consists essentially of two parts — an instrument for puncturing the skin, and 
another for promoting the flow of blood by removing atmospheric pressure from 
the punctured part. The puncture is effected by a lancet, the blade of which 
has the form of the cutting apparatus of the leech. This lancet is fixed in the 
mouth of a tube, and projects about the eighth of an inch beyond the edge of 
the tube. It may be elevated by a small lever, so that its point shall be within 
the tube, in which position it is secured by a catch. Attached to the opposite 
end of the tube, by a piece of vulcanized India-rubber, which acts as a spring, 
is a piston, which is pressed down by a rod, and, on removing the pressure, is 
drawn back by the India-rubber spring. The piston being pressed down, the 
open end of the tube in which the lancet is fixed, is placed over the part to be 
punctured: the pressure is now removed, when the piston is drawn back 
by the spring, and exhausting the air within the tube, the skin is forced up into 
the mouth of the tube. On loosening the lever, by which the lancet has been 
elevated, the latter is drawn down by a spring, also of vulcanized India-rubber, 
so as to effect the puncture. The cutting instrument is now removed, and a 
glass tube with a piston, similar to that already described, is placed over the 
puncture, the air within being exhausted so that the tube adheres to the part, 
and the blood flows freely into it. Half-a dozen or a dozen tubes, each of which 
would draw as much blood as a large leech, might be thus attached in two or 
three minutes. The apparatus, consisting of a cutting instrument and six or 
twelve suction tubes, together with sundry implements for cleaning the lancet 
and tubes after use, are contained in a small case. It is very neatly got up, and 
we understand from those who have used it, is very efficient. The idea, how- 
ever, is not new : so long ago as the year 1813, the silver medal was awarded at 
the Society of Arts to Mr. J. Whitford, of St. Bartholomew's Hospital, for the 
invention of a somewhat similar apparatus for the same purpose. In Mr. 
Whitford's apparatus the exhaustion was effected by a syringe, which was found 
to be inconvenient. The use of vulcanized India-rubber springs, attached to 
the pistons, by which efficient suction tubes are economically formed, is a great 
improvement in MM. Alexandre's apparatus. — Lond. Med. Journal, March, from 
Phar'm. Journal, February 1849. 



MEDICAL PATHOLOGY AND THERAPEUTICS AND PRACTICAL 

MEDICINE. 

13. On the Analogy and Differences between Tubercle and Scrofula. — M. A. 
Legrand concludes an elaborate and valuable series of papers, extending 
through several Nos. of the Revue Mddicale, for last year, the fruit of many 
years' research, he informs us, with the following summary of the results, at 
which he has arrived : — 

1. There undoubtedly exist analogies, which we may call symptomatic, be- 
tween tubercle and scrofula ; that is to say, one of these two morbid principles, 
the tubercular, may exhibit itself by symptoms which appear to belong to the 
other ; but this is not the case with regard to the latter. 2. Tubercle possesses, 
so to speak, its morbid individuality, its molecular element — the tubercular 



208 Progress of the Medical Sciences. [July 

globule — which is often met with in the scrofulous manifestations of tubercle. 

3. Scrofula is always deficient in the morbid molecular element, and its exist- 
ence is only proved by the constancy of the effects which are attributed to it. 

4. The chief, or even the only seat of tubercle is in the internal organs, and 
the external manifestations of the morbid principle irradiate from the centre to 
the circumference. 5. Scrofula comports itself quite otherwise, and manifesting 
itself on the skin or periosteum, irradiates thence towards the internal organs, 
which, however, it never disorganizes in the same manner as tubercle. G. 
Tubercle, in spite of the impoverishment of the blood it always induces, does 
not destroy, at least in the early periods, the inflammatory element, the fibrine, 
which well explains the occurrence of the phlegmasige, which so often complicate 
it, and which always hasten its disorganizing progress. 7. Scrofula likewise 
impoverishes the blood, but at the same time it seems to annihilate the inflam- 
matory element. Thus inflammations rarely complicate it, and when such 
complication does exist, it often favours the cure of the disease. 8. All the 
changes observed in the blood and urine of tuberculous and scrofulous patients, 
are evidently consecutive ; and they cannot be considered as the cause of these 
two diseases, whose principle is nevertheless very probably contained in the 
blood. 9. Finally, tubercle is never curable, or at least such cure constitutes 
a rare exception, while scrofula is almost always curable. — Revue Medicate, Nov. 
1848. 

14. On Spinal Meningitis. — M. Piorry, in a recent clinical lecture at the 
Hopital de la Pitie, called attention to an epidemic of spinal meningitis, in 
some respects similar to that observed at Strasbourg by MM. Forget and 
Tourdes. By these authors this disease was observed to prevail chiefly among 
soldiers, and that class of people who were congregated together in large 
numbers in the same localities. 

M. Piorry had been called to Corbeil by Dr. Liounet for the purpose of visit- 
ing certain patients then convalescent from spinal meningitis. The epidemic 
had prevailed in the country in the immediate neighbourhood of Corbeil, and 
in Corbeil itself. The patients observed by M. Liounet, manifested as symp- 
toms, intense headache, a sense of prickling and of pain in the limbs. Per- 
cussion in the course of the spine caused much pain. Convulsions, coma, 
diminution of power, and sometimes paralysis of the extremities, were also 
symptoms of the disease observed by M. Liounet. Frequent autopsies demon- 
strated the existence of pus effused between the archnoid and pia mater in the 
cervical region. The encephalon presented no particular morbid appearance. 
In his lecture, M. Piorry related the particulars of four cases, three of which 
terminated favourably, the fourth fatally ; of these we select the first. 

1. A young man aged twenty-two, retained as a prisoner in the Bastion since 
the insurrection of June. This patient presented the following symptoms: 
Pain in the neck, extreme rigidity of that part ; convulsive movements of the 
arms ; the fingers and toes were rigid and semiflexed ; the maintenance of the 
erect position almost impossible. He complained of excessive pain in the neck 
and back, augmented by percussion ; the sense of pain was more severe at night 
than during the day. There existed an evident tendency to stupor ; the spleen 
was enlarged. M. Piorry diagnosed spinal meningitis. The treatment adopted 
was the application of forty leeches to the neck, blisters along the spine, and 
the exhibition of the sulphate of quinine. On the following day the patient 
was slightly better, leeches were again applied, and a purgative injection ad- 
ministered. During many days little sensible improvement took place. At 
the visit of one day, he was found in a much worse condition than on his first 
admission. Leeches and blisters were again had recourse to ; at length con- 
valescence was established, and ultimately a complete cure obtained. 

In the examination of the body in the fatal case alluded to, the patches of 
Peyer in the lower part of the small intestines were congested, the last two or 
three exhibited superficial ulcerations. The spleen was enlarged; the brain 
presented nothing remarkable ; the surface of the cerebellum was slightly soft- 
ened at the side of the medulla, in the cervical region ; concrete pus was found 
effused between the archnoid and pia mater, forming a false membrane. At 



1849.] Medical Pathology and Therapeutics. 209 

the inferior part of the spine, also between the archnoicl and pia mater, there 
existed from three to four spoonfuls of liquid pus. The substance of the cord 
was not softened. 

In the fatal case above recorded, and in two of the others, the symptoms 
were in most points similar to those of the typhoid fever of France ; and in the 
above instance post-mortem examination also revealed similar lesions of the 
abdomen. In one case of the four, however, no typhoid symptoms were present, 
and there was none of the extension of the splenic dulness, loading of the colon 
with the air and fluid, which characterize, according to M. Piorry, the affection 
in question (the abdominal typhus of the Germans). Typhoid eruption (iaches 
septicemiques) was present in two cases, and absent in two. The symptoms 
referrible to the spine were the same in all the cases. 

From the observations which M. Piorry himself was enabled to make, as well 
as from those published in regard to the cerebro-spinal meningitis by MM. 
Faure-Villar, at Versailles, in 1839, Chauffral at Avignon, Tourdes and Forget 
at Strasbourg, he concludes that the exciting cause of spinal meningitis, is to 
be found in the over-crowding of prisons, bastions, &c, and that the agent of 
its production is an unknown poison, such a poison as is believed to exist in the 
case of cholera and other diseases of the same kind. M. Piorry attaches con- 
siderable importance to the power of energetic treatment when employed early 
in the disease, in being capable of preventing a fatal termination. — Monthly 
Retrospect, April 1849, from Gazette des Hopitaux, March 8, 1849. 

15. Causes and Morbid Anatomy of Mental Diseases. — Dr. John Webster, in 
an extremely interesting and valuable communication to the Royal Medical and 
Chirurgical Society (May 8), stated, in illustration of the comparative frequency 
of maclness in the two sexes, that out of 1798 lunatics admitted into Bethlem 
Hospital, during six years, ending the 31st of December last, 1094 were females, 
and only 704 male patients. He next alluded to the causes apparently produc- 
ing insanity, which he divided into moral and physical, besides hereditary 
tendency to mental disease. Of the male lunatics, nearly one half, or 346, be- 
came mad from moral causes ; whilst the proportion of females was not quite 
so considerable, being 489 of the entire number. By physical causes, less 
than one-fourth of the male lunatics, or 156, became insane; whereas, amongst 
the female patients, the proportion was rather larger, being 282. Hence, 
speaking generally, moral causes produced half the total cases ; but physical 
causes only one-fourth. The principal moral influence which occasioned 
insanity amongst males, was reverse of fortune, whereby 86 examples are 
recorded. Next, anxiety, which furnished 69 instances ; then religion, giving 
45 cases ; lastly, love, which caused the loss of reason in 18 men. Amongst 
female lunatics, anxiety was the most frequent moral cause, producing 79 in- 
stances out of the 489 patients classed under the above category; whilst 69 cases 
arose from religion; 62 from the loss of relatives; and 57 from the more power- 
ful influence of Cupid's tender passion upon the susceptible feelings of women. 
Fright caused insanity in 50 cases ; reverse of fortune in 49 ; whereas, amongst 
men, as already stated, the same cause produced nearly treble that amount, 
speaking comparatively. In regard to physical causes, of the 156 male lunatics 
so affected, 80 originated from intemperance ; and of the 282 female lunatics, 
similarly classified, 117 arose from puerperal disease. Other physical causes 
were subsequently mentioned by the author, before passing to the examination 
of hereditary tendency to mental complaints. Of 704 male lunatics previously 
enumerated, 219, or 31.10 per cent., had hereditary tendency to mania; but of 
the 1094 female insane patients, the proportion was larger — namely, 390, or 
37.47 per cent. The author, amongst other remarks respecting the influence 
of hereditary tendency in producing mental disease, said, such an important 
fact, wherever it exists, should be always well considered by parties forming 
matrimonial engagements ; especially, when both families are unfortunately so 
tainted. He next adverted to the age at which insanity is most likely to super- 
vene. In males, he stated the most susceptible time of life was from 30 to 40; 
but m females it was earlier, being from 20 to 30. The author subsequently 
noticed the two sections of psychological physicians now dividing the profes- 



210 Progress of the Medical Sciences. [July 

sion — namely, the " vitalists" and the " anatomists," of which latter body he is 
himself a disciple, since he considers their doctrine the most rational, and in a 
greater degree consistent with the present advanced state of pathological know- 
ledge respecting mental diseases. The author afterwards gave a synopsis of 
sixty-seven dissections made at Bethlem Hospital, of which the following is a 
summary of the diseased appearances observed in the brain and membranes. 
In 53 cases, effusion of water had taken place in the ventricles ; in 53 cases, 
also, there was infiltration of the pia mater; in 38, turgidity of the cerebral 
blood-vessels ; in 30, the archnoid membrane was thickened and opaque ; in 26, 
the colour of the brain was altered from its natural tint; in 15, there was an 
effusion of blood within the skull, besides other alterations of structure, as 
mentioned by the author. The organs of the chest were likewise more or less 
diseased in as many as 62 of the patients ; whilst in 30, morbid changes were 
likewise noticed in the abdominal viscera; so much so, indeed, was this the case, 
that the immediate cause of death, in a number of the insane patients referred 
to in the present communication, was apparently disease in these parts ; but 
more especially, affections of the organs of respiration. Dr. Webster then 
alluded to the long period during which some of the lunatics had laboured under 
mental aberration, particularly females, one female lunatic having constantly 
resided in the incurable ward at Bethlem Hospital for upwards of half a 
century, or actually fifty-four years ; thereby showing, that the loss of reason is 
sometimes not incompatible with longevity. After again referring to the deduc- 
tions contained in his previous papers communicated to the Society, the author 
concluded by remarking, that the facts and statements now brought forward, 
fully confirmed his former observations, and he hoped they might prove useful 
to students of medical psj^chologj 7 . — Lancet, May 19, 184-9. 

16. On Polydipsia. — M. Vigla took the occasion of an example of this 
rare form of disease being in the Hotel-Dieu to deliver a clinical lecture 
upon it. It occurred in the person of a shoemaker, set. 40, who, two months 
before admission, suffered from severe frontal neuralgia. Shortly before he 
came in, he was seized with so tormenting a thirst, that he was forced to 
drink six or seven quarts of water a day, and two or three by night. This 
state continued for three weeks, during which the neuralgia entirely left him ; 
but a week prior to admission the thirst diminished and the neuralgia returned. 
Blisters to the head and purgatives relieved this ; but the thirst now returned 
as intensely as ever. On the 2d of November, he was found to have passed 
from eight to ten pints of urine since the prior evening, which was of a very 
pale citron hue, inodorous, nearly neutral, and of a density (1002) but little 
above that of water, &c. The tongue was nearly normal, the gums pale, mouth 
dry, and spitting difficult, saliva slightly acid, and so spariDg that he could not 
swallow two mouthfuls without drinking ; appetite gone, having some desire 
for vegetable food, and a loathing for animal. No pain in the abdomen, and 
stools are normal. Skin dry, and very susceptible to cold. Some emaciation ; 
little sleep ; suspension of sexual desires ; pulse 56, and regular. 

There are three diseases in which excessive thirst and secretion of urine are 
prominent symptoms; polydipsia, diabetes mellitus, and diabetes insipidus. 
Polydipsia is distinguished from diabetes mellitus by there being no sugar in 
the urine, and mere congestion or augmentation of volume of the kidney, but 
no organic change. Although the odour of diabetic urine is slight, it is of a 
more annualized nature than that of polydipsia; and if the latter be left to 
itself, it passes into the putrefactive fermentation, while that of diabetes passes 
into the alcoholic, depositing a whitish substance, which is a true ferment. 
The difference of density sufficiently distinguishes the two urines ; for while 
that of diabetes furnishes a specific gravity of from 1026 to 1044, that of poly- 
dipsia furnishes one of but from 1000 to 1004, or at most 1008 ; the density in 
the one affection being greater, in the other less, than in any other disease, and 
forming the two extremes of the scale. The urine of diabetes polarizes light, 
which that of polydipsia does not. In diabetes, the appetite may be much in- 
creased, while in polydipsia it is diminished; meat and gelatinous aliment are 
taken and digested in the former, vegetables in the latter. Nutrition is much 






1849.] Medical Pathology and Therapeutics. 211 

more seriously affected in diabetes than in polydipsia ; the continual emaciation, 
in spite of enormous alimentation, observed in the one, not taking place in the 
other. The diabetic patient easily takes cold, each cold becoming more and 
more obstinate, and usually terminating in phthisis. All those patients who 
do not die of a complication of the original disease, die tuberculous, a termi- 
nation not observed in polydipsia. Arrived at such a period, the diabetes may 
seem cured; but in fact less sugar is secreted, because the patient now takes less 
food whence to elaborate it. Towards the end of the case the patient becomes 
oedematous, which he does not in polydipsia. Polydipsia does not easily make 
ravages in the constitution, the patient bearing it as well for twenty years as for 
six months, which is very far from being the case with diabetes. In both affec- 
tions, the complication of a febrile disease may temporarily suspend their 
course. In one case, seen by M. Vigla, the polydipsia was suspended during 
an intense reaction excited by blisters, and reappeared when this had subsided. 

As to diabetes insipidus, M. Vigla is aware of no well-ascertained example of 
such a disease, which, without sugar in the urine, gives rise to emaciation and 
eventual phthisis. 

The causes of polydipsia are unknown. It may occur at any age, in any cli- 
mate, and in either sex. Generally, its access is sudden, and it becomes fully 
developed in a few days. M. Vigla regards both it and bulimia as neuroses, 
deranging the health no more, or even less, than other neuroses. It obstinately 
resists all treatment ; the only remedies which are of any occasional avail being 
antispasmodics. — Brit, and For. Med.-Chir. Rev., April 1849, from Gazette des 
Edpitaux, 1848, No. 130. 

17. Effects of Cauterization in Inoculation with Virulent Poisonous Agents. — M. 
Parch APPEjn a communication to the French Academy of Medicine (Jan 8.), ex- 
pressed his regret that the confidence of medical men in this remedy had been 
shaken, especially in cases of the bite of a mad dog. He related the following 
experiments : 1. A quantity of extract of nux vomica, of the size of a pea, 
was introduced into a wound on the back of a young dog, and produced death in 
two hours. 2. A similar quantity was introduced into a wound in the foot. 
The limb was amputated. After twelve minutes, tetanus was complete, but was 
followed by recovery. 3. A wound in the foot, inoculated as above, was cau- 
terized with a red hot iron. The result was recovery. 

From these experiments it appears that the effect of nux vomica can be arrested 
by amputation, or destruction of the poisoned part. Now, as it appears that 
the virus of rabies requires a longer time to produce its effects than strychnia, 
the success of cauterization, in strychnia cases, should encourage us to practice 
it, to prevent absorption of the virus, from the bite of a mad dog. — London Journ. 
Med., March 1849. 

18. Period required for the Absorption of Virus. — M. Renault has communi- 
cated to the French Academy of Sciences the results of some experiments made 
at the Veterinary School of Alfort, the object of which was the determination 
of the period at which the action of a virus ceases to be local, and becomes 
general. 

This was endeavoured to be determined by ascertaining how soon a parcel of 
virus placed under the epidermis becomes absorbed ; or, in other words, how 
long is the period after inoculation within which we may destroy or remove the 
portion of skin under which such deposition has been made, without modifying 
the absorption of the virus, so as to prevent or sensibly modify the general 
effects. In thirteen experiments, the animals were inoculated with the matter 
of acute glanders, and the actual cautery applied, after previous excision of the 
congested parts, at periods after the inoculation varying in the different animals 
from ninety-six hours to one hour. In all, the animals became diseased. In another 
series of experiments, in which the virus of the rot of sheep was employed, it 
resulted that the virus was absorbed in five minutes. — Brit. &. For. Med.- 
Chir. Rev., April 1849, from Gazette Mddicale, Dec. 16th, 1848. 



212 Progress of the Medical Sciences. [July 

19. On the Simultaneous Development of Variola and Vaccinia. By MM. 
Herard and Bousquet. — M. Herard having had, at the Children's Hospital at 
Paris (where children are so wantonly exposed to the danger of contracting 
small-pox prior to their vaccination), the opportunity of observing eighteen 
cases of the co-existence of the two diseases, he is desirous of expressing his 
opinion upon the disputed question as to the degree of influence they exert 
upon each other. 

Of these eighteen children (from twenty months to four years old) seven died ; 
all these being, however, cachectic, or exhausted by prior disease. In them, the 
small-pox was rarely confluent, but it was irregular and ill developed. In the 
eleven cases which recovered, the eruption was discrete, rapid in its course, and 
unaccompanied by suppuration of the pustules, or tumefaction of the surrounding 
skin. The fever was slight, and the convalescence rapid. During this benign 
progress of these cases, the disease more than once proved very fatal to non-vacci- 
nated children. Had the vaccine acted injuriously in the seven children who died? 
MM. Eilliet, Barthez, and Legendre answer this question in the affirmative, be- 
lieving the vaccination hastens the evolution of the variola, and increases the 
debility — opinions with which M. Herard does not agree. He also, in the 
eleven successful cases, observed no difference produced in the mode of 
the development of the vaccine vesicle ; but in the seven children who died 
from various complications the vaccine was in a very languishing condition. The 
following are the general conclusions arrived at: 1. When the two eruptions 
are developed at the same time in a healthy child, the variola is advantageously 
modified. Its progress is more rapid, and the eruption is more discrete — taking 
on the character of varioloid. 2. Although vaccination is far from exerting the 
same effect, and especially in hospitals, on very young and diseased children, 
being innocent, it should be practiced. The danger in these cases is attributable 
to the small-pox, not to the vaccination, and is produced by complications and 
bad hygienic conditions. 3. It is not correct to say that the two eruptions 
exert a reciprocal modification. That which has the priority of invasion (not 
of infection) influences the other, but is not influenced by it; and as, in almost 
all cases, the vaccine, to become developed, must precede the variola, we may 
generally state that, in the cases where the diseases exist simultaneously, the 
vaccinia undergoes no modification. — U Union Medicate, Nos. 108, 109, 110. 

M. Bousquet states that an attentive examination of the voluminous corre- 
spondence of the Academie reveals the greatest discrepancy of opinion upon 
this subject. For his own part, he denies that vaccinia modifies the progress of 
small-pox advantageously ; and considers it a false deduction to suppose that, be- 
cause vaccinia prevents variola, it must restrain its advantages when the two 
diseases meet together. According to MM. Bayer and Clerault's statistics, of one 
hundred and eleven cases of simultaneous existence of the two diseases, twelve 
died, and M. Legendre states that nine of fifty-six died ; but small-pox, unaided 
by vaccination, is not more fatal than this. Of M. Herard's eighteen cases, 
seven died, and there is no reason to agree with him that the remaining eleven 
were milder because of the vaccinia. MM. Rilliet and Barthez declare that 
in very young infants it increases danger ; but M. Bousquet agrees with neither 
party. Those who maintain that small-pox is rendered more discrete by vacci- 
nation, take only the successful cases, forgetting that, in the natural small-pox, 
the discrete exceed the confluent cases in the proportion of ten to one. 

M. Bousquet therefore denies that the two eruptions exert any reciprocal reac- 
tion ; and the nearer they appear together, the more independent are they of 
each other. Suppose, e. g., that the two could appear at the same hour ; then 
each would pursue its ordinary course, just as if the other were not present. 
But supposing the one eruption appears after the other, all will depend upon the 
space of time separating them. If this be only some hours, or even two or 
three days, all passes on as just stated. The case is different, when one of 
these eruptions is greatly in advance of the other. If this is not to such an 
extent to exclude, the eruptions progress together, but not in parallel. The 
most advanced always keeps its advantage, and finishes at its ordinary epoch, 
without having undergone any change in form or duration. The other follows 
it at a distance ; but after the variolous capacity of the subject has become ex- 



1849.] Medical Pathology and Therapeutics. 213 

hausted by the first, the second dies away. In these influences there is nothing 
direct, active, or special ; they are the consequences of the faculty possessed by 
the eruptions of supplying or substituting each other. The vaccinia does not 
arrest the variola, but it is the variola that stops short in the face of the 
vaccinia ; and, conversely, variola does not cut short the course of vaccinia, but 
this last interrupts its own course in presence of the variola. It is the right of 
precedence ; and the more widely the two eruptions are separated, the more 
readily do they exclude each other ; while the nearer they are together, the more 
independently do they proceed. Considered in themselves, the vaccine and 
variolous virus are so little capable of destroying each other's energy, that if 
they are mixed together, and inoculation performed with the mixture, two 
perfectly distinct eruptions are produced. Considered as regards their effects, 
we cannot say that vaccinia cures variola, or even, rigorously speaking, that it 
prevents it. It takes its place, stands in its stead, and is neither more nor less 
than a substitution. Thus, so far from explaining the operation of vaccinia by 
the supposed opposition it offers to variola, we would rather do so by the analogy 
and reciprocal action of the two diseases. — Brit. & For. Med.-Chir. Rev., April 
1849, from Bulletin de Therapeutique, torn. xxv. pp. 342-52. 

20. On the Influence of Physical Agents in Variola. By M. Serres. — The 
skin is pre-eminently the seat of the variolous eruption, not so much on 
account of its structure as its external position, and consequent exposure to the 
action of the air. Thus, those portions of the skin which, by the hair covering 
them, are somewhat protected from this influence, are those least affected by 
pustules. And if portions of the internal organs, naturally protected from the 
influence of the air, become exposed to this, no matter what their structure or 
functions may be, they also become covered with the pustules. Thus, in the 
same child, we may see the pharynx, epiglottis, and sometimes the trachea, 
exhibiting pustules, while the oesophagus is quite free. In trichiasis, in 
protrusion of the rectum, in protrusion of the vagina or uterus, the internal 
surface, now placed in the same condition as the external, furnishes pustules 
like it. It is to the exclusion of the air that the ectrotic mode of treating 
small-pox owes its success. 

Seeing that the atmosphere produces so manifest an effect on the development 
of the pustules, we should expect that changes in its condition would not be 
without their influence. And thus it is, when we examine into the causes of 
the mortality of the disease prior to vaccination, we find that inordinate dryness 
of the air was one of the conditions most favorable to its aggravation, and this 
whether it co-existed with an excess of cold or heat. So, too, the history of 
the epidemics df this disease shows that they have always proved more fatal in 
the dry south, than in the more humid north. During 1817-19, M. Serres' 
small-pox patient^ were placed in small, ill-ventilated wards, which were also 
damp ; but the cases of confluent small-pox manifested little severity. When, 
however, these wards were abandoned for spacious ones situated on the fourth 
story, very dry, and looking north and south, being very hot in summer, and 
very cold in winter, the mortality became so much greater, as to lead to the 
speedy resumption of the old, damp wards on the ground floor. 

Does the same observation apply to vaccinia ; and is this why revaccination 
has been so much more successful in the north than in the south ? — Brit, and 
For. Med.-Chir. Rev., from Gazette Medicate de Paris, 1848, No. 41. 

21. Nux Vomica in Intestinal Obstructions. — It is notorious that certain ob- 
stinate cases of intestinal obstruction owe their difficulty to our ignorance of 
their cause ; equally notorious that our practice is often empirical. In the 
" Transactions of the Medical Society of Rouliers/ 7 Dr. Ossieur has communi- 
cated some valuable information concerning the use of nux vomica in such 
cases. He says it produces a degree of excitement, more or less energetic, 
where there is deficient intestinal innervation, which often restores them to 
their natural action. Assuming this — and the fact is undisputed — we cannot 
refuse our assent to the doctrine that the medicine may act upon the muscular 
fibres of the intestines as it does on the muscles generally. In support of this 



214 Progress of the Medical Sciences. [July 

view, Dr. Ossieur refers to the action of nux vomica in chronic catarrh, with 
relaxation of the mucous membrane, to lead colic, to prolapsus ani in children, 
and to atonic diarrhoea. He relates two cases of obstinate constipation, which, 
resisting all other means, yielded at once to the nux vomica. — Medical Times, 
May 26, 1849. 

22. Extractum Cotyledonis Umbilici in Epilepsy. — Dr. Joseph Bullae, of 
Southampton, recommends [Provincial Med. and Surg. Journ., May 23, 1849) 
the use of the extractum cotyledonis umbilici, for the cure of epilepsy. 
" Several years ago," he states, " the expressed juice of the cotyledon umbili- 
cus, or napplewort, was recommended to a lady who had compound epilepsy, 
which had not yielded to medical treatment, and under its use the disease was 
entirely removed and has not returned. The patient was under the care of my 
friend Mr. Salter, of Poole, who watched the case with much interest, and 
mentioned the fact to me. Subsequently, my brother, Dr. W. Bullar, recom- 
mended the juice for a child in this neighbourhood, where the plant grew, and 
the epilepsy was cured. Rather more than a year ago I requested Mr. Randall, 
chemist, of Southampton, to prepare an extract of the expressed juice, in order 
to give the remedy a trial, and from the experience I have since had, I have no 
doubt in my own mind of the anti-epileptic power of the medicine, although 
sufficient time has not yet passed to bring forward cases as perfect cures. 

"From the experience Dr. B. has had in a considerable number of cases 
(several of which were of a very hopeless kind), long perseverance, he says, is 
necessary ; and if the number and violence of the fits are lessened, there are 
good grounds for hope and further perseverance. In all the cases, there has 
been a marked diminution in the violence and frequency of the attacks ; and as, 
in two cases (one of which I heard to-day), it has first increased the violence 
of the fit, and as, in others, there have been transient symptoms of increased 
nervousness and headache, requiring a short suspension, I am in hopes that it 
may prove a true anti-epileptic. It is certainly in many cases nervo-tonic, as 
the improved nervous tone is shown by quieter sleep, fewer dreams, better 
spirits, more ability to take exercise, and a consciousness of general improve- 
ment. It has no other action on the body that I am aware of. It certainly 
produces no action on the bowels, for when there has been costiveness (which 
is so commonly the case in epileptics) the usual medicines to keep up a natural 
action have been required. I have used it with the precautions quinine 
requires in ague, attending to the general health, and endeavouring to remove 
and rectify faulty secretions, or any obvious local disorder. Some of the 
patients to whom I have given it have been in fair bodily health ; in others the 
nervous system has been weak and excitable ; in others weak and exhausted. 
In children, it is advisable to begin with a few brisk purgatives, in case the 
epilepsy may depend on worms ; and in young men, the state of the urethra 
should be examined ; as that state of debility kept up by seminal discharges, con- 
sequent on an irritable urethra, which so disposes the system to epilepsy, count- 
eracts the beneficial influence of the medicine. If there is habitual costiveness, 
a simple dinner pill (as the compound rhubarb) is necessary. When, with an 
excitable nervous system, there is a foul tongue, yellowish eye, turbid, acid 
urine, and offensive motions, the state of the blood on which this depends must 
be corrected by a course of aperients, which excite the gastro-intestinal mucous 
membrane, liver, and kidneys to throw off the impurities, without weakening 
the general powers (aided by diet and hygienic means) ; for, unless the fluids 
are thus filtered and purified, no specific remedy can with any reason be 
expected to have a fair chance. 

"The juice is prepared by bruising the leaves and leaf-stalks in a mortar, 
and expressing the juice from the bruised mass through a cloth. One tea- 
spoonful, twice a day, of the juice. I have prescribed five grains of the extract 
(which is made by evaporating this juice), twice a day, and occasionally three 
times. It may happen, that the disease may be much shortened by increasing 
the dose. This is matter for further trial." 



1849.] Surgery. 215 

SURGICAL PATHOLOGY AND THERAPEUTICS, AND PRACTICAL 

SURGERY. 

23. Pathology and Treatment of the Deafness attendant upon Old Age. — Mr. 
Joseph Toynbee, in a very important paper contributed to the Monthly Journal of 
Med. Science (Feb. 1849), contends that the conclusion to which most medical men 
have arrived, that senile deafness depends upon a gradual and natural decay of 
the powers of the organ of hearing, is not well founded. He states, that "the 
results of his experience tend to show, that this decline of the power of hearing, 
in old age, is dependent upon the influences to which aged persons are fre- 
quently subjected; namely, the prolonged stay in warm and close rooms, the 
avoidance of the open air, the cessation from bodily exertion, the want of atten- 
tion to diet, and to the healthy performance of the functions of the skin ; and 
that it does not depend upon the decline of nervous power, or upon an atrophy 
of the tissues which compose the organ of hearing. On the contrary, an exten- 
sive field of post-mortem investigation has demonstrated, that the most frequent 
pathological condition found in cases of senile deafness, is a considerable in- 
crease in the substance of the mucous membrane lining the tympanic cavities ; 
and that the evidences of atrophy of the tissues are very rare. The pathological 
condition second in frequency in these cases, is a thickening of the membrana 
tympani; and the third consists in the presence of bands of adhesions, which 
connect together various parts contained in the tympanic cavity and these con- 
tents to the walls of the tympanum. The examination, during life, of elderly 
patients suffering from deafness, quite agrees with the results of the patholo- 
gical researches. Thus, while the external surface of the membrana tympani 
remains smooth and shining, its substance is seen to be whiter than natural; 
upon attempting a forcible expiration with closed nostrils, air is heard by the 
otoscope* to enter the tympanic cavity, but it produces an unnatural sound : the 
hearing is generally worse during an attack of cold, and in dull weather." 

Mr. Toynbee relates five cases, with dissections, illustrative of these views. 

24. Traumatic Pleuro-pneumonia. — Traumatic lesions of the lungs are far 
from being invariably fatal. Thus we frequently meet with very serious cases, 
accompanied by circumstances against which it would, at first sight, seem 
difficult for the patient to struggle, which are ultimately cured without leaving 
any trace. 

One of the gardes mobiles, a man about thirty years of age, was wounded in 
the chest by a ball which lodged in the lungs. A few days after his entrance 
into, the hospital, he expectorated purulent mucus, mixed with blood ; there was 
fever, accompanied by all the symptoms of inflammation of the parenchyma of 
the lungs. At this time, tlie patient was on nearly full diet, but had no wine 
allowed him. M. Mal gaigne having made inquiries regarding the circumstances 
from which this attack arose, discovered that, one or two evenings before the 
expectoration came on, the man had drunk a bottle of wine which had been con- 
veyed to him by his friends. An abscess soon appeared at the portion of the 
lungs where the ball had lodged, and broke into the bronchi, after which the 
patient expectorated pure pus. 

The condition of the patient became so serious that M. Malgaigne, on one 
occasion, thought his case utterly hopeless. He was in a state of the most 
complete prostration. The pus had forced for itself a passage into the pleura, 
where a purulent effusion was formed, which escaped both by expectoration and 
through the wound in the chest. Notwithstanding the serious nature of these 
circumstances, the patient recovered, and was dismissed from the hospital when 
in a very satisfactory state; although not kept till his complete recovery, 
owing to the discovery that, in addition to the wine allowed by the hospital 

* An elastic tube, twenty inches in length, each extremity having fixed upon it a piece 
of ivory or ebony : one orifice is introduced into the ear of the surgeon, and the other 
into that of the patient, while the latter attempts to make a forcible expiration with 
closed mouth and nostrils. 



216 Progress of the Medical Sciences. [July 

regulations, the patient, notwithstanding M. Malgaigne's injunctions to the 
contrary, continued to drink wine surreptitiously conveyed to him from without. 

In reference to this case, M. Malgaigne took occasion to point out that it was 
one of those cases which show the admirable results that may be expected from 
a sound constitution, and keeping the patient on a good diet. For how can the 
system bear up against the debility which necessarily results from continual 
suppuration, if the diet be low? Attention is often so exclusively directed 
towards the organic condition of the organs, that the vital condition is too often 
lost sight of, although it is equally worthy of observation. It is generally sup- 
posed that where there is inflammation of the lungs the patient must be kept 
low, but M. Malgaigne observes, here, that we should look to the state of the 
stomach, which is to be discovered, not by percussion or palpation, but by the 
manner in which that organ performs its functions. If it performs its func- 
tions in a perfectly normal manner, M. Malgaigne is of opinion that the patient 
will invariably be benefited by a good diet, however serious the wounds may 
appear to be. 

However much we may agree with the opinions of M. Malgaigne, on the sub- 
ject of the diet to be given to the wounded, it must not be forgotten that, gen- 
erally speaking, traumatic inflammations of the lungs are less severe, and less 
often fatal, than idiopathic inflammations, a circumstance that may not have 
been wholly devoid of influence here. — Monthly Retrospect, April 1849, from 
Gazette des Hopitaux, 1848. 

25. On the Utility and Necessity of performing Paracentesis Thoracis in cer- 
tain cases of Pneumothorax. By Hamilton Roe, M. D. [Proceedings of Royal 
Med. and Chirurg. Soc, April 10, 1849). — The object of this paper is to show 
that pneumothorax is not a necessarily fatal disease, and that paracentesis is 
the best remedy which can be employed for its cure. The author adverts to the 
fact, that the disease arises from a great variety of causes, and that not unfre- 
quently there is either no alteration of structure in the lungs, or so little as to 
warrant us in supposing that it might be cured. He relates two fatal cases that 
have come under his own observation, in which paracentesis was recommended 
by him, but not performed, and in which, after death, it was found that there 
was in one instance no perforation of the lung, and no disease of the lung what- 
ever ; while in the other the opening in the pleura was very small, and although 
four small caverns and a small number of tubercles of inconsiderable size 
existed in it, there was no organic disease immediately fatal, and life might 
have been at least prolonged, had the lung been relieved from the pressure of 
the air in the pleura by the operation of paracentesis. The author then refers 
to several other writers, who have narrated similar cases, and especially to the 
thesis of M. Saussier, who has shown that the possible causes of pneumothorax 
are seventeen. The author himself arranges the varieties of cases under four 
heads : 1. Those where the air is secreted by the pleura ; 2, those where it 
arises from decomposition of fluid ; 3, the cases where it escapes from a dis- 
tended or ruptured emphysematous cell ; and 4, those where it issues from a 
fissure in the lung. The first three varieties are susceptible of cure, and the 
fourth is not necessarily fatal. After describing the symptoms distinguishing 
these different varieties of the disease, the author proceeds to show that the 
mere presence of air in the pleura is not a source of danger ; that the air may 
in some cases be absorbed; and that it is, therefore, only where air is "accumu- 
lated in such quantity as to cause great difficulty of breathing, that we are called 
on to remove it by tapping the chest. The operation, in order to be successful, 
ought to be performed before the lung, by compression, has become cammed, 
and the other lung congested. The objection, that the air admitted from with- 
out will itself compress the lung, the author meets by saying, "that if the 
wound made by the canula in tapping be kept open, the lung, if healthy, will 
expand on being relieved from pressure, and may, if the air can escape as fast 
as it enters, not only come into contact with the costal pleura, but contract 
adhesions to it, and obliterate the pleural cavity." In support of this state- 
ment, he gives the particulars of a case observed and related by Mr. Benjamin 
Phillips, in which, by sloughing of the soft parts, the cavity of the pleura was 



1849.] Surgery- 217 

completely laid open, in two intercostal spaces, to the extent of several inches, 
and where, " at every act of ordinary inspiration, the lung came into close contact 
with the ribs ; at every expiration, the lung retreated to the extent of half an 
inch from the ribs." The author then refers to published reports of nineteen 
cases, in which paracentesis thoracis has been performed for pneumothorax, 
in ten cases successfully ; and after observing that the question, whether the 
opening made in the operation should be closed or kept open is yet to be 
decided, but that it seems to him desirable to keep it open when the air enters 
the pleura through an opening in the lung, and to close it in the other cases, 
he concludes his paper by relating a case in which the wound was left open 
with a favourable result. — London Medical Gazette, April 27, 1849. 

26. Use of Nitrate of Silver for White Swellings, Hydrarthrosis, and Venereal 
Bubo. — M. Decaisne, military surgeon at Anvers, has published, in the Archives 
de Medecine Militaire, some observations on this subject; two remarkable cases 
are given. One of the patients was a man of 27 years of age, and of a lym- 
phatic temperament, who, on the night of the 5th of February, 1847, felt a se- 
vere pain in the right knee ; swelling soon followed, and the patient was unable 
to use the limb. Every means were had recourse to for his relief — antiphlo- 
gistics, baths, calomel and opium, blisters, iodine, mercurial ointment, compres- 
sion and douches, without any effect in arresting its progress into regular white- 
swelling. In the month of July, M. Decaisne began the use of an ointment of 
nitrate of silver, when the knee was double its natural size, was so tender that 
the patient dreaded its being touched, all motion in the joint impossible, and 
with three fistulous openings at the inner side of the joint ; amputation appeared 
inevitable ; and in this very unfavourable aspect of affairs, it was ordered to em- 
ploy friction twice a day of an ointment composed of one gros (59.1 grains) of 
the salt of silver to an ounce of lard ; about two gros of the ointment were used 
at each application. Under this treatment the pain sensibly abated in a few 
days, the swelling gradually diminished, and in about a month the improve- 
ment, in every respect, was considerable. During the month of August, the 
proportion of the nitrate of silver to the lard was increased to a gros and a half 
or two gros to the ounce of lard, and at length, at the end of the month, the cure 
was complete, and the young man only experienced a slight stiffness in bend- 
ing the knee. The second case was that of a young boy, attacked with a white- 
swelling of the radio-carpal articulation. Previously to the employment of the 
ointment of the nitrate of silver in this case, a number of more active remedies 
had been tried in vain ; the swelling was considerable, and it was necessary to 
open a large abscess near the articulation. After using the ointment of the ni- 
trate of silver for two months the amelioration was considerable, or rather the 
cure was completed. 

After giving the above cases, the Journal de Medecine adds the following re- 
marks : Other cases, where the salt of silver in the form of ointment have been 
recently published in the Archives de la Medecine Beige, by Professor Uytterhoe- 
ven ; he used it in a great number of cases, but all those he details were dropsy 
of joints, not white-swelling: the ointment of nitrate of silver possesses a reso- 
lutive action upon those serous swellings of joints. This therapeutic agent 
should not be employed until the inflammatory stage has passed. 

La making the ointment it is necessary to dissolve the nitrate of silver in wa- 
■:■ Before incorporating it with the lard, to prevent the rubefacient or cauteriz- 
ing effect of the metallic salt on the skin, or the formation of vesicles, which 
without this precaution would be inevitable. Generally smart pain, but tran- 
sient, is experienced on the application of this remedy at the place on which it 
is rubbed. 

The power of this ointment to resolve venereal buboes has been experienced 
in the practice of M. Lutens ; he dissolved a drachm of the salt in a sufficient 
quantity of distilled water, and then mixed it with an ounce of lard. His mode 
of using it is this, — about two drachms of the ointment are used at each rub- 
bing ; after three or four days the skin becomes black and shining ; instead of 
suspending the treatment until the epidermis desquamates fully, the scales are 
detached with the nail, or a spatula, and the frictions immediately recom- 



218 Progress of the Medical Sciences. [July 

menced. These frictions never occasion pain, but sometimes a slight uneasi- 
ness. M. Lutens uses this ointment also in glandular swellings of the neck and 
groin, and in all stages of bubo. — Dub. Med. Press, March 1849. 

27. On Valvular Obstructions as a Cause of Retention of Urine. — M. Mercier 
has written two papers in the Gazette des Hopitaux (23d and 27th Jan.), on 
the remedial measures for retention of urine in old people. M. Mercier states 
that his researches have shown him that the cause of retention, in these cases, 
is what he terms valvular obstruction, which he divides into two kinds, muscu- 
lar and prostatic ; the former, he states, arises from the anatomical arrangement 
of the muscular fibres at the orifice of the bladder; presenting, even in their 
normal condition, a transverse elevation of the mucous membrane covering 
them ; this, he states, increases to such an extent, in old people, as to present 
a true valvular obstruction ; and, to remedy this cause of retention, he proposes 
incising the valvular elevation at several points by means of an instrument, of 
the form of the ordinary short-curved sound, used for exploring the bladder, 
and containing a small cutting blade which can be projected for the purpose of 
incising the valve, after the instrument used as an exploratory sound has ascer- 
tained its size and position. He states, that at first he tried excision of the 
projecting portion, but found this means uncertain, and that he now finds deep 
incising across the structure of the valve perfectly sufficient. If no accidents 
occur during the first few days, he applies no other treatment (nothing is said 
of what these accidents may be) except for the purpose of preventing hemor- 
rhage, which has occasionally, though rarely, occurred; he recommends that the 
bladder should not be allowed to be empty, and therefore directs the use of 
injections of cold water; he finds the presence of the urine sufficient to prevent 
too rapid union of the incised edges. 

By the term prostatic valvular obstruction is meant, the enlargement and 
projection of the middle lobe of the prostate. For the cure of this cause of 
retention, it is proposed to twist off or break down the projecting portion. This 
is effected by means of the lithotrite of M. Jacobson, which consists of two 
branches enclosed in a sheath ; the branch corresponding to the convexity of 
the curve is formed of separate portions articulated together, so that when the 
blades are projected from the sheath the articulated branch forms a sort of 
noose ; when the instrument is closed it presents the appearance and serves the 
purpose of an ordinary sound. For the operation at present in question, the 
instrument introduced closed, is used as a sound, and when the valvular pro- 
jection of the prostate is felt by it, the instrument is opened, the blades are pro- 
jected from the sheath, and the enlargement of the gland is seized in the noose, 
and then, by drawing back the blades within the sheath, the instrument is 
closed, and the valvular tumour either twisted off or broken up into fragments, 
[!] which become decomposed in the bladder and pass of with the urine. The 
only after treatment adopted is the injection of cold water into the bladder to 
prevent hemorrhage. 

[M. Mercier says nothing of the use of anaesthetic agents in this operation. 
To the unfortunate subjects of valvular obstruction, who fall into M. M.'s 
hands, chloroform would be a real boon.] 

It is also mentioned that M. Mequel d'Amboise has obtained favourable 
results in such cases, by the employment of a method at once ingenious #nd 
very simple [save the mark!] This simple measure consists in taking six small 
leaden pellets of a conical form, the base of each being about two-fifths of an inch 
in diameter, and to the apex of each is attached a long and delicate stalk of very 
flexible iron wire ; these are introduced one by one into the bladder by means 
of a silver catheter open at both ends ; and this being effected, the catheter is 
withdrawn. The operator then unites all the flexible iron wires which pro- 
ject at the orifice of the urethra, and by drawing them towards himself, he pulls 
all the leaden cones into a mass at the neck of the bladder ; this he does with 
the intention of causing compression of the enlarged lobe of the prostate, but, 
according to Mr. Phillips, it would seem probable that the glandular projection 
is entangled amongst, and crushed and torn by, the forcible collection of the 
leaden cones. When the operation is completed, the cones are pushed back 



1849.] Surgery. 219 

into the bladder, and then removed one by one by means of the attached wires. 
— Monthly Retrospect, April 1849. 

28. On the Evils attending Excisipn of the Tonsils. — Mr. Harvey, in a paper 
read before the London Medical Society, stated that his attention had long been 
directed to the question how far chronic enlargement of the tonsils affected the 
permeability of the Eustachian tube. The result of the examination of nearly 
a hundred cases had convinced him that the bodies in question had really 
nothing to do, mechanically, with obstructing that tube. After giving an 
anatomical description of the tonsils, he proceeded to show that when they be- 
came enlarged, it was always downwards and forwards — that is, in the direction 
of the mouth and of the oesophagus ; and that, consequently, the effect upon the 
mouth of the Eustachian tube was that of dilatation, and not, as had been sup- 
posed, of occlusion, to that orifice. The author next enumerated the causes of 
chronic enlargement of the tonsils, the chief of which were cold, catarrhal 
affections, deranged digestion, the eruptive fevers, &c. Aphthoid affections 
were a frequent source of disease in the middle ear. With respect to occlusion 
of the Eustachian passage, he considered it to exist much less frequently than 
had been supposed ; and in cases where this occlusion did exist, it was not from 
the enlarged tonsils pressing upon the mouth of the tube, but from thickening, 
the result of inflammation of the lining membrane. Excision of the tonsils was 
not, therefore, expedient ; indeed, in many cases which he had examined, that 
proceeding had been attended with enlargement of the follicles of the pharynx, 
continued heat and thirst, constant desire for deglutition, disturbance of the 
general health, and impairment of the voice. Enlarged tonsils were more fre- 
quently found in females than males ; and when enlarged in childhood, generally 
assumed their natural size at puberty. They appeared to the author to have 
some intimate sympathy with the sexual organization. The treatment of 
enlargement of the tonsils consisted of small doses of the bichloride of mercury 
and colchicum ; the latter, with guaiacum, was most efficacious. He concluded 
by remarking, that in some cases in which the tonsils had been removed, the 
hearing, previously intact, had become impaired. He illustrated his remarks 
with the relation of several cases. 

In the discussion which ensued on this paper, it was observed, by Mr. Head- 
land, that in all the cases he had seen, in which the tonsils had been excised 
in children, the patients had departed from their general health. For that 
reason he had long since discountenanced the operation. 

Dr. Crisp thought the deafness in these cases was rather the result of con- 
gestion than of pressure. He considered that some connection existed between 
the tonsils and the generative organs. Tonsils enlarged in a similar way to 
other glandular organs, and were amenable to the same treatment. 

Mr. Pilcher agreed with the author, that enlarged tonsils, per se, had little 
to do with the Eustachian passages ; the irritation, however, produced by these 
organs when inflamed, would extend up the Eustachian tube, and deafness 
might be the result. Any remedies applied for the cure or relief of enlarged 
tonsils, he considered would be ineffective without the general health was 
attended to. 

Mr. Harvey had always found that, when the general health was improved 
under the use of tonics and mineral acids, and the local application of iodine 
and other agents, the tonsils usually resumed their normal condition. When 
very large, occasional scarification was of great service. — London. Med. Gaz., 
April 1849. 

29. Arterial Compression as an Antiphlogistic. — Dr. Henroz de Marche has 
published a work on the value of compressing the brachial artery in cases of 
whitlow to check the inflammatory process in the finger ; this seems but an ex- 
aggeration of M. Cerdy's principle of keeping the limb elevated so as to lessen 
the force of the arterial circulation in the inflamed part. Dr. Henroz was one 
day in his garden pruning an arbutus, and got a prick of a thorn in his left 
ring-finger at the inner side of the third phalanx; the thorn was extracted, and 
for twenty-four hours he felt no uneasiness in the part; the finger at this time 



220 Progress of the Medical Sciences. [July 

began to swell rapidly, and to grow red, and the inflammation extended by de- 
grees to the palm and back of the hand. On the fourth day, the pain was pul- 
satile and severe ; he could not sleep ; had great thirst ; skin hot, and pulse 
frequent; the axillary glands were swollen but indolent. Stuping, leeches, 
poultices, opiates, mercurial frictions, were in their turn tried without advan- 
tage. It then occurred to M. Henroz to try compression of the brachial artery, 
which he did immediately with his thumb ; instantly, the severe pain which he 
had endured for five days ceased, as if by magic, and he was able, without the 
slightest uneasiness, to put his hand into any position he pleased, and even the 
redness disappeared completely. However, as it was impossible to maintain 
the pressure in this manner for any length of time, he contrived an instrument 
for the purpose, so simple in its construction as perhaps to make it a valuable 
aid in such cases in the country, where more perfect ones could not be readily 
had. It was applied on the brachial artery, and the same good effects imme- 
diately followed as when compression was made with the thumb ; it was left on 
for three hours, during which the pain in the hand did not recur for an instant; 
it was pale and cool, and the swelling had diminished. Fearing that a longer 
interruption to the circulation might produce ill consequences, M. Henroz sus- 
pended the compression for three-quarters of an hour. The pain returned ; 
pressure was again made, but this time it was on the ulnar not the brachial ar- 
tery, and the symptoms were as suddenly relieved as in the former case. Com- 
pression on the artery was thus continued from half-past twelve at noon until 
five o'clock in the evening, as well as the palm and dorsum of the hand with 
firm compresses of wadding, at which time the tumefaction of the hand and 
finger was permanently reduced, as also the tenderness ; the symptoms of reac- 
tion had ceased, and there were no longer pain or fever. In the evening, press- 
ure was again made and continued all night ; the next day the cure was com- 
plete. 

The same treatment was employed by M. Henroz with the same result on a 
young girl who had a very severe whitlow ; in this case, in which the affection 
was eight days progressing, the pain left the part the instant the compression 
was applied, and the cure was complete in thirty-six hours. — Journal de Mede- 
cine. 

30. Treatment of Gonorrhoea by Vinum Colchici. — Dr. Ficimus, of Dresden, 
confirms the opinion formed by Eisenmann, of the value of vinum colchici in 
gonorrhoea. He gives from twenty-five to thirty drops three times a day, com- 
bined with tincture opii, enjoining at the same time a low diet, warm bath, &c. 
These means he has found attended with unprecedented success in the treat- 
ment of gonorrhoea, and other inflammatory discharges from the urethra in 
males and from the vagina and uterus in females. The details of ten cases are 
given in illustration. — Med. Gaz., from Casper's Wochenschrift, Aug. 26, 1848. 

31. Case of Exfoliation of the Anterior Arch of the Atlas. (Proceedings Royal 
Med. and Chirurg. Soc.) By Robert Wade, Esq. — The subject of this affection 
(aged thirty-five) first came under the author's notice at the Westminster Dis- 
pensary, in October, 1845. He then had a large, sloughy ulcer occupying the 
back of the pharynx, at the centre of which dead bone could be felt with a 
probe. He had previously suffered from extensive exfoliation of the upper jaw, 
and lost one of the spongy bones. Twelve years had elapsed since he had pri- 
mary venereal disease, for which he was salivated, and was again subjected to 
the influence of mercury, by fumigations, for ulcerated throat. A course of 
iodide of potassium in sarsaparilla re-established his health for a time, but 
his throat again became sore two years afterwards. The same treatment was 
resorted to repeatedly with varying success. Latterly, he had suffered from 
pain in the neck, and from attacks of muscular rigidity in the same part. In 
one of these spasmodic attacks he had been alarmed by feeling something give 
way in the back of his neck, " with a loud crack, like the report of a pistol." On 
looking into the mouth, some coagulated blood was seen adhering to the ulcer. 
After this, the spasmodic attacks became less frequent and severe ; and at the 
expiration of five months, the author observed a small portion of bone project- 






1849.] Surgery. 221 

ing into the pharynx, and, with very little difficulty, removed the greater part 
of the anterior arch of the atlas, with the entire articulating surface of the 
odontoid process of the axis. Caution was enjoined for a time, and the patient 
was enabled to resume his usual occupations in three months ; the throat, how- 
ever, has continued, from time to time, to be subject to attacks of ulceration. 
The power of rotating the head is now nearly perfect, but he has a catching 
pain at the back of the neck when he attempts to bend his head forwards. 

Mr. Prescott Hewett brought forward two preparations, which had refer- 
ence to the paper which had just been read. These preparations were pre- 
sented to the pathological museum of St. George's Hospital, in 1835, by Mr. 
Keate, who removed them, in 1810, from a man who had been affected with 
syphilis, and had taken large quantities of mercury. One of these preparations 
was a large exfoliation from the anterior part of the atlas, on which might be 
detected a small portion of the articulating surface for the odontoid process. 
This portion was perfectly smooth, and of the size of a split pea; the remainder 
of the bone was rough, and consisted only of about two-thirds of the thickness 
of the anterior arch of this vertebra ; it measured an inch in length. The other 
preparation, which was taken from the same patient, consisted of an entensive 
exfoliation from the basilar surface of the occipital, including the luxated edge 
of that bone. After the removal of these pieces oT bone, as well as exfoliations 
from other parts, the patient recovered his former health and strength. The 
details of this case were published by Mr. Keate in the Medical Gazette for 1835. 

Mr. Wade replied, in answer to a question from the president, that his pa- 
tient retained, unimpaired, the power of rotating the head, but that it could 
only be bent forward to a very slight extent, not more than an inch. With regard 
to the case mentioned by Mr. Hewett, as having occurred at St. George's Hos- 
pital, in 1810, although, in some respects, resembling his own, there was this 
important difference, that in Mr. Hewett' s there had been exfoliation of a part 
only of the anterior arch of the atlas, with but a portion of the articulating sur- 
face for the odontoid process ; so that, in fact, some degree of bony support had 
still remained in front of that process. Mr. Wade believed that the case brought 
by him before the Society was the only one recorded in which exfoliation of the 
whole of the anterior arch of the atlas, with the entire articulating surface for 
the odontoid process of the axis, had occurred, affording a satisfactory proof 
that the transverse ligament has sufficient strength to retain that process in its 
place. — Lancet, Feb. 24. 

32. New Variety of Luxation of the Humerus. By M. Malgaigne. — A man, 
set. 63, presented himself to M. Malgaigne, 31st of October, with a luxation of 
the humerus, which had occurred on the 16th of the preceding August ; and 
the subject being a thin one, he was enabled to convince himself that it was a 
variety of the accident of which he knew of no other example. The man had 
been pitched to a distance from the top of a high wagon on to the ground, and 
had fallen on his shoulder, the arm being at the same time compressed against 
the trunk. A careful examination showed that the head of the bone had been 
carried upwards and forwards above the acromio-coracoid ligament and the 
coracoid process, which was so concealed by the head of the bone as not to be 
felt. The exact seat of the head was on the acromio-coracoid ligament, ante- 
riorly and superiorly to the coracoid process ; so that it might be termed the 
supra-coracoid luxation of "the humerus. It was irreducible at so remote a 
period. — Brit. & For. Med.-CJiir. Rev., from Rev. Med. Cliir., torn. v. p. 30. 

33. Staphylorapliy . — M. Gerdy exhibited to the National Academy of Medi- 
cine a lad, fifteen years of age, on whom he had performed the operation of 
staphyloraphy, and whose pronunciation was entirely re-established. The 
cleft-palate in this patient, he stated, was so large, that the thumb could not 
cover the opening ; there was no separation of the bone. Pronunciation was 
painful, and very imperfect. The fault of pronunciation was principally on the 
consonants, especially on the c, s, j, ch, n, b ; in fact, the whole of the consonants 
were very much altered from the air escaping by the nostrils. The sounds 
were so very confused, that the person could hardly be understood. At present, 

No. XXXV.— July, 1849. 15 



222 Progress of the Medical Sciences. [July 

the patient is cured, with the exception of a very slight embarrassment, the 
results of previous habits of speaking : at the same time, the deglutition of fluid, 
formerly accompanied with difficulty, is now quite easy. M. Gerdy made use 
of the ordinary process of refreshing the edges; but in place of the interrupted 
suture, which he always thought bad, from its forming a ring, the pressure of 
which brought on sloughing of the part, he preferred the quilled suture, which 
forms only a half circle, and does not strangulate the approximated portions. 
Instead of quills, he used two small pieces of liquorice root, moistened in warm 
water; he removed the first thread on the 6th day, and the rest on the 7th. M. 
Gerdy attributed the success principally to the employment of the quilled 
suture, which he considers preferable to all others for this purpose. — Monthly 
Retrospect, from Gaz. des Hopitaux, Oct. 1848. 

34. Ligature of the External Iliac Artery. — T. W. Nunn, Esq., has communi- 
cated to the Lancet (May 5) a case of femoral aneurism about the size of half a 
large orange, in a man 43 years of age. A ligature was applied to the external 
iliac, while the patient was under the influence of chloroform, Jan. 26th. The 
ligature came away on the 32d day (23d Feb.), and on the 23d March the pa- 
tient resumed his employment. The temperature of the limb was well main- 
tained throughout. On the evening after the operation, the thermometer indi- 
cated in the ham of the ligatured side a heat of 95°; while in the ham of the 
sound side, and in the axilla, a temperature of 92° only was attained. Indeed, 
many days after the operation, the right limb appeared to the hand to be the 
warmer of the two, though the thermometer did not verify the impression. I 
consider the chloroform to have been the cause of the troublesome cough men- 
tioned, but fortunately produced no serious harm. 

35. Femoral Aneurism. Mr. Tufnell communicated to the Surgical Society of 
Ireland (Feb. 17, 1849) the following extremely interesting case of femoral 
aneurism. The subject of it was an Irishman, a sergeant of infantry, aged 34, 
five feet ten inches in height, a strong and very healthy man, of temperate 
habits, and extreme moral courage. On the 10th of March 1848, whilst at 
drill, performing the extension motions, and endeavouring to touch the ground 
without bending the knees, he felt something snap in the fold of the left groin. 
He did not suffer pain or inconvenience, and made no report of the circumstance. 
The day but one following he marched a distance of eighteen Irish miles. His 
foot and leg swelled upon this occasion, and continued to do so for several days, 
when, finding the oedema so great as to prevent him from wearing his boot, he 
went into hospital, complaining of being foot-sore from the march. He rested 
in bed for a short time, and the swelling gradually subsided. He returned, 
therefore, to his duty, and continued at it for upwards of a week, when, being 
engaged in the escort of provisions, and finding himself unequal for the duty, 
he was readmitted into hospital, complaining of oedema and leg weariness as 
before. Rest in the recumbent position again relieved the swelling, and he re- 
ported himself as fit for his duty. He was accordingly a second time discharged, 
and was immediately sent (being a steady, intelligent man) on the recruiting 
service to England. 

Here, during a period of several months, he performed every duty required of 
him. He stated that, shortly after leaving the regiment, the swelling of the leg 
became constant, and a small tumour gradually formed in the fold of the left thigh, 
which at first he could perceive in the night, when in bed, ticking like a clock, 
but that afterwards, as the swelling increased, the pulsation became indistinct. 
He never sought for medical relief, but was daily walking about, searching for 
recruits. This state of things continued until early in the month of October, 
when the pain in the thigh and leg (especially after standing for several hours), 
became so severe as to oblige him to apply for permission to return to his regi- 
ment. He was accordingly recalled, but on rejoining his corps, he made no 
further complaint, and continued to perform the ordinary duties of a sergeant 
until the 22d of December last. On that day he went to the hospital, and ex- 
hibited to the medical officer of his corps a large, pale tumour, situated at the 






1849.] Surgery. 223 

fold of the left thigh, immediately below Poupart's ligament, and encroaching 
upwards upon the abdomen. 

The emergency of the case was reported by the medical officer to Sir James 
Pitcairn, the inspector-general of hospitals, who immediately ordered a medical 
board to assemble and report upon the practicability of removing the man to 
Dublin, in order that he might have the advantage of treatment in the Royal 
Infirmary. The board having reported that he could be safely removed by short 
stages and under proper escort, he was accordingly ordered up, and arrived at 
the Military Hospital on the 20th of January, and was placed under Dr. Fox's 
care. 

The aspect of the tumour at this time was frightful from its size, and bore 
somewhat the appearance of fungous hsematodes. It rose in a sugar-loaf form 
from the centre of the left groin, measuring one foot eleven inches round the 
base, and eleven inches across the top. Its base was pink and slightly inflamed, 
its apex purple, with the skin considerably abraded, marking an incipient slough. 
Pulsation was visible by placing a piece of paper on the surface, or applying 
the hands to the sides of the tumour, whilst a distinct single bruit could be 
heard throughout. The tumour encroached greatly upon the abdomen, its upper 
border being level with the brim of the pelvis. The thigh was enormously 
swollen, being twice the size of the other ; but the limb below was not corre- 
spondingly increased, the foot being only one inch and a-half, and the calf of the 
leg only three inches larger than that of the opposite side. The temperature 
was equal in both ; the posterior tibial artery could not be felt on the affected 
side, but pulsation in the popliteal was doubtful. 

To view this man lying in bed, no suspicion of such disease could have been 
entertained. His eye was clear and bright, his countenance placid, not in any 
way expressive of suffering, and he made no complaint. When questioned, he 
said that the pain, which had been severe during the journey, had subsided, 
and that he felt tolerably well. His tongue was moist ; his pulse one hundred, 
regular, and soft ; he had slept soundly the preceding night under the influence 
of an anodyne, and awoke free from headache ; all that he complained of was, 
that his appetite was failing, and that he felt correspondingly weak. 

A consultation on the case was held upon the 22d, Sir James Pitcairn, 
Staff-Surgeons Sinclair, Scott, and Fox, and Assistant-Surgeons Barrett and 
Ivey, with Sir Philip Crampton, Mr. Cusack, and Dr. Adams being present. It 
was unanimously determined, under the circumstances, not to interfere, unless 
compelled to do so by the sack giving way, but to leave the case to nature, in 
the hope that, as the pulsation was very indistinct and gradually declining, it 
might spontaneously cease, the artery be obliterated above, the sack become 
filled with coagula, and the aneurism eventually slough out ; such a termina- 
tion having twice occurred in somewhat similar cases in the practice of Sir 
Philip Crampton. 

Cold lotions were ordered to be applied to the tumour, the patient's strength 
to be kept up by strong beef-tea, and rest to be procured by opium at night. 

On the 23d, no change whatever had taken place. 

On the 24th, he was not so well. He had perspired profusely through the 
night, the sweat having an acid, rheumatic odour. The tongue was dry, and 
he complained of thirst. The pulse was increased in frequency, being one 
hundred and twenty in the minute. Pain had returned in the tumour, which, 
he said, felt as if hot water were poured upon it. The pulsation was not per- 
ceptible, and the bruit could be distinguished only by applying the ear directly 
to the tumour ; it was inaudible through the medium of a stethoscope. The 
surface of the tumour was more livid, and oedema slightly increased ; but the 
temperature of the leg was natural and equal to that of the opposite limb. 

The same treatment was ordered to be continued. 

On the 25th there was an apparent improvement in his general condition, the 
pulse having come down to one hundred and eight, the tongue become moist, 
and the thirst less urgent. The pain in the tumour had subsided, and he com- 
plained only when the limb was stirred ; but the tumour itself had increased in 
size, its surface being livid, indeed almost black, the skin abraded, and weeping 
sanguinous fluid sufficient to tinge the cloth by which the lotion was applied. 



224 Progress of the Medical Sciences. [July 

The discoloration of the surface extended over the brim of the pelvis, giving 
an ecchymosed appearance to the integuments down as low as the side of the 
nates. The temperature of the limb was unchanged. 

During the course of this day, a bulging prominence presented itself to the 
outer edge of the tumour, having much the appearance of a knuckle of livid 
intestine. Drs. Fox and Barrett, who were in close attendance upon the patient, 
now determined to cut down through the centre of the tumour, and tie the vessel 
as it entered the sack, as soon as ever the first oozing of blood should appear. 

Their opinion, indeed, was not to wait for the occurrence of this event, lest 
the jet of blood should be too great for the patient to bear, but to anticipate 
what now appeared to be almost inevitable. The general impression, however, 
upon the minds of the members of the consultation being, that, from the mass 
of coagulum then lying between the artery and the surface of the tumour, the 
vent would not be followed by violent hemorrhage, they were inclined to hold 
their hands, and give nature every chance, waiting ready to interfere as soon as 
all further hope was removed. 

This event occurred at 6 P. M. The patient was in the act of moving the 
limb when the aneurism suddenly burst, the blood spouting in a heavy jet full 
three feet from the bed ! Compression upon the aorta was instantly made by 
Dr. Barrett, whilst Dr. Fox, assisted by Dr. Ivey, carried a free incision through 
the centre of the tumour, (turning out the mass of clot and gore contained in the 
sac,) and quickly placing a ligature round the mouth of the artery as it entered 
the sac. No hemorrhage took place, and not an ounce of blood was lost during 
the operation, which was borne with the greatest fortitude by the patient, who 
expressed himself as relieved by the removal of the tension of the tumour. An 
opiate was subsequently administered, and he slept soundly for four hours. He 
then dosed at intervals, between which he appeared to become fainter and fainter. 
Wine had been freely given both before and after the operation ; but, in spite of all 
stimulants, his extremities gradually grew cold, and he died slowly off, at four 
o'clock, on the morning of the 26th, ten hours after the vessel had been secured. 
There was no return of hemorrhage from the lower end of the artery, and the 
ligature after death was found firmly and closely fixed round the mouth of the 
vessel. And here I cannot refrain from testifying to the able manner in which 
this operation was performed, under circumstances of no ordinary difficulty, by 
Dr. Fox and the gentleman associated with him. The sudden loss of blood, con- 
sequent upon the rupture of the sac, though borne against for a time, appears to 
have been too great for the powers of life ultimately to withstand. 

Upon examining the body thirty hours after death, it presented a very dif- 
ferent appearance, as far as regards the tumour, from what it bore during 
life, its contents being removed, and the integuments of the groin lying flaccid 
and flat. The superior extremities were muscular, and the thorax and ribs 
well clothed, although, judging from the comparative size of the lower ex- 
tremities, as exhibited in the drawing and cast, it might be inferred that 
the patient was emaciated, and ran down. On opening the cavity of the 
abdomen, the viscera and peritoneum were in a perfectly healthy state. The 
iliac arteries were healthy, and no abnormal condition of the parts could 
be detected, except that the tendons of the oblique and transversalis mus- 
cles on the left side were loose and lying in a fold, having, during life, been 
distended and pushed upwards by the aneurismal sac. The lymphatic glands 
were numerous and enlarged. 

Upon dissecting the aneurism itself by reflecting the integuments, the sac 
was found to originate from the femoral artery, immediately after passing from 
beneath Poupart's ligament. The sac was of an hourglass form, being con- 
stricted by the fascia lata, the portion beneath the fascia extending in an oblique 
line downwards to the canal in the adductors ; the portion above the fascia rising 
directly forwards and upwards, forming the tumour represented by the cast. 
Anteriorly, the tumour was covered by the sartorius muscle, which was spread 
over it tothe width of four inches ; posteriorly, it sank deep into the structures 
of the thigh, pressing against the capsule of the hip-joint, as well as against the 
neck of the femur. This pressure had been sufficient to create inflammation of 
the synovial membrane of the joint, as well as the cartilage on the head of the 



1849.] Surgery* 225 

bone, which bore an arborescent appearance from red vessels ramifying in it* 
The periosteum was also removed from the anterior part of the neck of the 
femur, the bone being abraded and rough. To the outer side the sack was 
bounded by the shaft of the femur, and to the inner side it wended its way 
through the adductor muscles, the fibres of which (together with all the others 
in the neighbourhood), were stretched around the sac, forming as it were its 
superficial coat, the middle being a condensation of the tissues, and the inner- 
most a lining of fibrine. The sac was still circumscribed below. 

Upon examining the preparation, and tracing the iliac artery from above, 
it appears to be perfectly healthy > and of a natural size. It enters the sac by a 
small rounded opening, the edges of which are abraded by the ligature which 
was placed upon it as a temporary restraint to the hemorrhage, prior to securing 
the vessel above. The sac itself is polished throughout, lined by a thin layer 
of fibrine, rendered smooth by the friction of the blood. It measures, in its 
present state, after being immersed in alum, (and thereby greatly constringed,) 
eleven inches in length, and seventeen in circumference. 

Its inferior connection with the artery is similar to the superior, being per- 
fectly round and even, situated from it at a distance of three inches in a direct 
line. The femoral artery beyond the sac is perfectly healthy, running in its 
usual course to the canal in the adductors, at which spot it has been divided 
across. The artery, therefore, retains its normal condition, except as regards 
the formation of the aneurismal sac. 

Not so the vein. Viewed from above, it is seen to be separated from the 
artery, the sac of the aneurism carrying it off at an angle, and pushing it 
rather to the outer side of the artery, and after traversing the superior surface 
of the aneurism for a couple of inches, it becomes obliterated, not permitting 
even a probe to pass. Below the tumour it has become completely transposed, 
lying altogether to the outer side of the artery, and maintaining this situation 
until it reaches the canal in the adductors, where it winds round the vessel and 
regains its natural position. From the sac, for the distance of two and a-half 
inches, it has become obliterated, assuming the appearance of, and feeling to 
the touch, like an artery plugged up with fibrine. Below this point it becomes 
pervious, and at the entrance to the tendinous canal resumes its normal size and 
shape. The vessels arising from the femoral artery are all obliterated at the 
sac, and, as it were, imbedded in its walls. The crural nerves are greatly 
stretched, flattened, and apparently enlarged. 

These are the principal points to be observed in the morbid specimen itself. 
"The one, however," remarked Mr. Tufnell, "to which our attention as sur- 
geons should be directed, is : — What mode of treatment could have been adopted 
that would have afforded any prospect of saving life ? 

" In the first place, the tumour had acquired such an enormous size, and so 
encroached upon the contents of the abdomen, lying, as it were, over and upon 
the external iliac artery, as to render it almost impossible to get at this vessel 
whilst the sac remained entire ; the incision ordinarily made for the purpose of 
securing the external iliac artery, instead of coming down upon it, would have 
disclosed only the sac itself, with the external oblique and transversalis fascia 
distended upon it. The projection of the tumour into the abdomen precluded, 
therefore, this operation, unless it was preceded by evacuation of the contents 
of the sac, thereby restoring Poupart's ligament and its component tendons to 
their usual site. This, then, I consider, (if a similar case should occur,) ought 
to be the primary step, and that the operation performed by Br. Fox, of cutting 
boldly through the centre of the tumour, turning out its contents, and tying 
the vessel as it entered the sac, should be the first thing done. The next step 
should be the placing of a ligature on the external iliac artery ; and the final 
one, the removal of the limb at the hip. 

" 'Heroic' as this may appear, I feel certain that nothing short of it could 
offer any chance of life. Suppose that, instead of resorting to removal of the 
limb, we secure the artery only. We leave the patient then with the supply of 
blood to the limb almost totally cut off, for the pressure of the sac has oblite- 
rated nearly every branch of communication with the vessels above, and gangrene 
of the limb, I may say, would be inevitable. Should this event, by some possi» 



226 Progress of the Medical Sciences. [July 

bility, not occur, there would still remain a cavity in the muscles of the limb, a 
vast suppurating sac, from which hectic would assuredly follow, and quickly 
run the patient down. - 

" There would also, in addition, exist general synovitis of the joint and erosion 
of the neck of the bone. These, however, depending upon a cause — namely, 
the pressure of the sac — which would now be removed, I will not throw much 
stress upon them, as they might spontaneously cease, and the reasons I have 
given above are alone, I think, fully sufficient to warrant the operation of re- 
moving the joint of the hip. 

" This form of amputation has for the most part hitherto proved fatal, not from 
the loss of blood, but from the shock to the nervous system in general, and it 
remains for experience to show whether, under the influence of chloroform, we 
may not anticipate happier results. 

" Such, I consider, will be the case ; for, judging from the numerous in- 
stances in which I have myself used and seen chloroform employed by others, 
there has not appeared to be greater appreciation of injury to the frame where 
amputation has been resorted to than where a single tooth has been removed/ 

" Dr. Bellingham had had the opportunity of seeing this case, and would take 
the liberty of offering a few remarks upon it. Many similar cases might, he 
observed, be found in the works of the older writers on surgery, in some of which 
a spontaneous cure took place, in consequence of the aneurism increasing so 
much in bulk as to press upon and obliterate the artery above the seat of the 
aneurism, after which suppuration ensued in the sac, and the patient ultimately 
recovered. In the case before the society, when the patient entered the Mili- 
tary Infirmary, there appeared to be no chance of a spontaneous cure taking 
place, the skin being, at that time, on the point of giving way. If, on the other 
hand, the common iliac artery had been tied, gangrene would undoubtedly have 
set in, or the sac would have suppurated, and the patient have been finally run 
down by hectic fever. With respect to Mr. Tufnell's suggestion of amputation 
at the hip joint, he was inclined to think that an operation which had succeeded 
in so few cases must inevitably have proved fatal in a case of so serious a 
nature as this, where the limb was extensively engorged. He considered that 
the plan recommended by Mr. Adams was that which gave the only chance 
of success. Whether the disease was left to itself, or whether the external 
iliac artery was tied, he must equally have died ; but he thought the sac (as 
Mr. Adams had recommended), might with advantage have been laid open, 
the coagula turned out, and the case treated as a wounded artery, the vessel 
being tied both above and below the aneurismal sac." — Dublin Medical Press, 
March 7, 1849. 

36. Popliteal Aneurism communicating with the Knee Joint. Amputation of the 
Thigh. — Mr. Adams related to the Surgical Society of Ireland the case of a co- 
loured man named Flood, set. 50, a cook on board a steam vessel. About five 
months ago, he accidentally discovered a tumour, about the size of a hen's egg, in 
the popliteal region, to which, as it gave him no pain nor inconvenience at that 
time, he paid little attention. Soon afterwards, he engaged himself on board 
of a vessel destined for Ireland, and, during the voyage, the tumour gradually 
enlarged, and grew painful, disabling him from making any use of the limb, 
and even obliging him to remain in his berth during the latter half of the voy- 
age. Upon his arrival in Dublin, the pain in the part grew severe, and on the 
6th of January, on application, he was at once admitted into the Richmond 
Hospital, where he (Mr. Adams) saw him on the following day. In the popli- 
teal space of the right leg, a very large and shining tumour presented itself, ac- 
companied with some tumefaction of the knee joint and oedema of the leg and 
foot. The pulse 84, the tongue white, and he complained of pain in the back 
part of the leg along the course of the sciatic nerve. On laying the hand upon 
the swollen limb, its surface was found to be remarkably hot. The popliteal 
tumour was tender to the touch, and felt remarkably tense. No pulsation was 
communicated to the fingers as long as pressure was lightly made ; but upon 
making a firmer pressure with the hand, a movement was communicated to the 
fingers corresponding with the pulse of the patient. Pulsation ceased altoge- 



1849.] Surgery. 227 

ther when the femoral artery was compressed. On applying the stethoscope 
to the tumour, a muffled bruit de soufflet was perceived. The nature of the case 
was still further apparent from the fact that pressure upon the femoral artery 
had the effect of causing the tumour to become flaccid. No pulsation whatever 
could be felt in the arteries of the leg. 

A consultation of the surgeons of the Richmond Hospital was then held, and 
though it was admitted on all hands to be a most unpromising case, still the 
proposition was made that treatment by pressure should get a trial. For Mr. 
Adams' part, it was his opinion that it was not a case for pressure, and that 
the aneurism was too large, and had been too much neglected to admit of any 
other resource than amputation; yet, as the urgency of the case was not extreme, 
he made no objection to the trial of pressure in the first instance. The man, 
however, would not tolerate pressure for any length of time, and though a va- 
riety of instruments were tried, and even opiates administered to enable him to 
endure the compression, the man himself insisted upon a more active practice 
being resorted to. It was observed that, since the day of his admission, the tu- 
mour underwent an increase in size, the measure of its circumference having 
been enlarged by a full inch and a half, and an ecchymosed spot appeared on 
the skin at the inner side of the knee. Under these circumstances, all idea of 
any operation for aneurism was abandoned, and on the 8th of January the limb 
was amputated about the middle of the thigh. Mr. Adams said his reason for 
not employing the ligature of the femoral artery in this case, was on account of 
the very large size of the aneurism ; his own experience had taught him that, in 
cases where the popliteal aneurism was large, the tying of the artery was almost 
invariably followed by gangrene of the limb. This circumstance, he thought, 
admitted of an anatomical explanation. The principal reason why gangrene 
attended the majority of such cases was, as he conceived, that the anastomosing 
arteries arise from the popliteal artery so near to each other, that, if the aneuris- 
mal tumour be allowed to attain a large size, these vessels, either in their origin 
or course, will be so much implicated as to be rendered null and void as means 
of carrying on the circuitous and intermediate course of the blood from the 
femoral into the arteries of the leg, when the former artery is tied. Whether 
this theory was correct or not, some might question ; but from his own expe- 
rience in a considerable number of cases, he could confidently state that, where 
the aneurism had attained a large size, mortification of the limb almost inevita- 
bly followed the use of the ligature. Another argument against the employ- 
ment of the ligature in such cases was, that, where the aneurismal sac had ac- 
quired a large size, suppuration was apt to ensue, ending in the rupture of its 
walls — an event which was followed by secondary hemorrhage and fatal con- 
stitutional irritation. He was aware, he will admit, of one case, where the 
artery having been tied, and mortification having ensued, the limb was success- 
fully removed while the gangrene was still spreading : but this he believed to 
be an uncommon case, and rare cases are not to be made rules for practice. As 
to the case of Flood, the opinion entertained by the surgeons of the Richmond 
Hospital and by himself was, that amputation was the only resource. This 
opinion seemed in accordance with that of one of the most eminent French sur- 
geons (Baron Boyer), as applied to such cases. Boyer was one of those practi- 
tioners who resembled very much Percival Pott, of England. This eminent French 
surgeon, writing in his 80th year, after an extensive practice spread over more 
than fifty years, expresses himself nearly as follows in the second volume of his 
Surgery : — " In popliteal aneurisms of large size, accompanied with symptoms 
of immediate rupture, great tumefaction, tension of the skin, cedematous en- 
gorgement of the limb, violent pain in the tumour, and in which there are 
grounds to suspect pressure has caused caries in the femur or tibia : in such 
cases, there is evidently no other means of saving the patient's life than ampu- 
tation of the limb." 

The amputation in Flood's case was performed under the influence of chlo- 
roform. 

Dissection of the amjmtated limb. — The limb measured no less than nineteen 
inches in its greatest circumference, being seven inches more than the sound 
limb. The aneurismal tumour was well defined above and below, and measured 



228 Progress of the Medical Sciences. [July 

nine inches in its longest and five inches in its shortest or transverse diameter. 
Posteriorly, both on the inside and outside of the limb, the tumour was bounded 
by the heads of the gastrocnemii muscles, which seemed to form a kind of mus- 
cular sac to cover it. The tendon of the biceps, instead of presenting, as it 
usually did, a round cord, was spread out into a fascia, which also covered la- 
terally the aneurismal sac. The next circumstance that attracted attention was 
an aperture in the sac, situated just near the place where the inner hamstring 
and gastrocnemii muscles crossed each other, through which the blood escaped 
from the sac, and thus was accounted for the ecchymosis observed on the inner 
and lower side of the knee on the day preceding the operation — an occurrence 
which, when it took place in connection with an aneurism, gave good grounds 
for the surmise that the latter had commenced to become diffused. It was also 
interesting to observe that, in this case, the aneurismal tumour grew from the 
anterior wall of the artery, and not from its posterior wall, as usually happened 
with aneurisms in this locality ; hence the artery was nearer to the skin than the 
aneurismal tumour. Upon passing a finger deep into the aneurismal sac, it 
was found that the latter communicated with the knee joint. This was the 
chief singularity in the case, and it clearly accounted for the swelling and in- 
flammation in the joint, observed before its removal from the body. Indeed, he 
was not aware of a single case of an aneurism in this situation communicating 
with the knee joint, but there may be such on record. This circumstance of 
course tended considerably to aggravate the case, for the effused blood in the 
knee joint had led to synovial inflammation and to a softening of the articular 
cartilages, particularly to that which covered the patella. The specimen, too, 
was interesting in this point of view, in showing the anatomical appearances 
of an early stage of synovitis seldom seen. Dissection also showed that the pain 
felt along the limb was attributable to the pressure of the aneurismal sac upon 
the sciatic nerve, which was situated immediately behind it, and seemed to have 
been considerably stretched ; and the oedema might be explained by the press- 
ure exercised on the lymphatic vessels and vein. On examining the lower end 
of the femur, it was found to be very porous in one situation, as if it were cor- 
roded, and presenting an elevated ridge — a circumstance which had, before the 
limb was removed, attracted much notice. The periosteum over this roughened 
portion of bone was thickened, and came completely away from the bone when 
the sac was pulled from its situation. Since the operation, the man had gone 
on very favourably. It was then twenty-six days since it had been performed, 
and he had seldom seen a stump so well (as the cast would show), in so short 
a period. — Dublin Med. Press, Feb. 1849. 

37. Popliteal Aneurism cured by Compression. — Mr. Tufnell communicated 
to the Surgical Society of Ireland (April 16th), a case in which both lower 
extremities were the subject of popliteal aneurism within a period of fifteen 
months, and in which compression was resorted to, each time, with perfect 
success. 

The subject of the case was a sawyer, 27 years of age, who came under Mr. 
T.'s care on the 3d of November, 1847. Four months previously he had been 
suffering from constant aching pain in the right ham, which first occurred 
whilst running. He did not take much notice of it, and continued at his 
labour. He had formerly been a spirit drinker ; but, having taken the pledge, 
had kept it up to the time of the races, when he began again to drink to excess ; 
and he stated that the throbbing and pain had both sensibly increased after 
each intoxication. He had at the same time (four months before) also con- 
tracted venereal sores, for which he had been placed under the influence of 
mercury. The superficial inguinal glands had been inflamed, and at the period 
of applying for advice were irritable and tender. His health, he said, had 
latterly declined, he sweated upon any exertion, was readily frightened, and 
suffered from occasional palpitation ; his pulse was 90 and irregular, but the 
sounds of the heart were natural. 

The tumour itself filled the whole popliteal space, measuring three inches and 
a half across by three inches from above downwards. Its contents were per- 
fectly fluid, a loud bruit accompanying the entrance of the blood when the 



1849.] Surgery. 229 

limb was horizontal, which was indistinct when the patient stood erect. The 
centre of the tumour was painful: the integuments covering the sac, though 
not discoloured, felt to the touch scarcely thicker than a crown-piece. The 
temperature of the tumour was sensibly lower than that of the adjacent parts. 

Pressure upon any portion of the femoral artery completely controlled the 
pulsation, the blood flying into the sac on its removal with a loud whirr and a 
jerk that caused much pain to the patient. He had constant numbness of the 
leg and foot, as also oedema of the limb. 

Treatment was commenced upon November 5th, at two P. M. Twelve 
ounces of blood of a highly carbonaceous character were taken from the arm, 
and a drachm of the compound powder of jalap administered. At six P. M. 
pressure was applied. Read's instrument was placed upon the artery in the 
groin, and Savigny's ring tourniquet at the middle third of the thigh. The 
pulsation was entirely checked, and the patient instructed how to alternate 
pressure. This was kept up through the night until six A. M., when the pain 
became severe, and he removed the instruments altogether. 

Nov. 6th, second day. Pressure was reapplied as before. Patient slept at 
intervals with the instrument on : pulse 78 and full ; bowels affected once ; no 
change in the tumour. Ordered to repeat the compound powder of jalap and 
pressure as before. 

7th, third day. Inguinal glands inflamed ; Read's instrument consequently 
removed, and the patient instructed how to make pressure on the artery with 
his thumb against the pubis, a lodger keeping his hand upon the tumour to 
ascertain the slightest return of pulsation, and to direct increased pressure 
accordingly. The ring tourniquet was moved to the entrance to the canal in 
the adductors. At the evening visit, the leg was found to be oedematous, and 
the patient complaining of numbness throughout the limb. This was speedily 
removed by bandaging with a flannel roller, and elevating the limb on a 
stretcher made for the purpose. 

8th, fourth day. Patient making no complaint ; the ring tourniquet has 
been continued on the thigh, and pressure by a seven-pound weight sub- 
stituted for that of the thumb in the groin. Ordered to repeat the compound 
powder of jalap. 

9th, fifth day. Says he has not slept ; that there is much pain in the tumour ; 
that he dreads unscrewing the ring tourniquet from the increased pain occa- 
sioned by the jet of blood into the sac ; patient slightly feverish, and complain- 
ing of headache ; bowels moved freely by the cathartic. Ordered to continue 
pressure, and repeat the jalap as before. 

10th, sixth day. The pain in the tumour diminished towards morning, when 
the patient slept, and awoke free from thirst. He states that he does not now 
feel the blood jerk into the sac as heretofore, and that he does not mind its 
influx. Two clamps were substituted for the ring tourniquet and weight, one 
being placed at the centre of Scarpa's space, the other at the upper portion of 
the canal in the adductors. 

11th, seventh day. Experienced much pain in the tumour and down the leg 
all the morning ; at noon, whilst dozing, he was awakened by a sudden, acute, 
burning pain in the tumour and leg, which for two hours was very severe ; it 
then gradually subsided ; and, on removing the pressure, all pulsation had 
ceased. When visited at six P. M., the foot and toes were cold, but friction 
speedily restored warmth, which was kept up by an extra sock and flannel roller. 

12th, eighth day. Sac solid ; not the slightest thrill through the tumour ; a 
large collateral vessel running down over the centre of its surface ; slight 
numbness only of the limb ; temperature natural ; compression continued for 
precaution's sake. When visited at six P. M., he was found lying intoxicated 
in the bed. 

13th, ninth day. Apparently not the worse for his debauch ; all pressure 
removed, a bandage being fastened to the heel of his sock and to a belt around 
his waist to prevent sudden and complete extension of the limb during sleep. 

18th. Seven days since pulsation ceased, and thirteen since compression 
was commenced. The tumour is now perfectly smooth and hard, and appears 
to be directly under the skin : superiorly, it fills the whole space between the 



230 Progress of the Medical Sciences. [July 

hamstring tendons, and, inferiorly, sinks deep "between the heads of the gastro- 
cnemius muscle. Sensation is perfect both in the foot and leg, slight numbness 
only remaining ; circulation is assisted by three superficial vessels : one running 
down over the centre of the tumour ; a second on the outside over the head of 
the fibula ; and a third on the inside of the knee. Is taking exercise with the 
aid of a stick ; in every respect perfectly well. 

On the 10th of December, he returned to his work as a sawyer (under man in 
a pit), and continued at uninterrupted employ until the 13th of November, 
1848. He presented himself again on this day, stating that he was afraid 
something was the matter with the opposite knee, as it had for some short time 
felt stiff. He had not run, jumped, or taken any violent exercise, but had been 
working in the wet, and he thought, therefore, that the pain was rheumatic. 

Deeming it almost certain, from his history, that aneurism was about to form, 
I examined the part most carefully, but not the slightest tumour, bruit, or 
other diagnostic sign, could be found to exist in the ham. The temperature of 
the limb was natural, the posterior tibial artery could be felt at the ankle, and 
there was no oedema of the foot. 

He was desired to foment the joint, and attend again in a few days. On the 
26th, he made his appearance, and in this brief interval a considerable change 
had taken place. Pulsation was now perceptible, and, upon examination by the 
fingers, a tumour could be felt deep in the popliteal space, two inches and a 
half in length by an inch and a half in breadth, the contents of which were 
fluid, and into which the blood entered with much force, and a loud single 
souffle. The pulse was 84. The action of the heart was regular. No trace 
of disease could be detected in this organ ; but the patient stated that occa- 
sionally a slight difficulty of breathing and tightness across the chest would 
exist. 

During this fortnight, he had been following his occupation as a sawyer. On 
the 27th of November, treatment was a second time commenced in the lodgings 
of the patient, which were now removed to 72 Sir John Rogerson's Quay. A 
ring tourniquet, on Savigny's principle, but fitted with Dr. Carte's elastic 
apparatus, was placed upon the middle third of the thigh, and the patient 
directed to make pressure upon the artery in the groin with his thumb, or a 
seven-pound weight, when he wished to relieve the other point of compression. 
He wore the tourniquet without inconvenience for six hours, then removed it 
and went to sleep. 

28th. The instrument was readjusted, and pressure continued as before ; 
no change. 

30th. Progressing favourably ; less pulsation, and the bruit not so distinctly 
heard ; pulse 72; sleeps soundly at night by relaxing the pressure. 

December 3d. Dr. Carte's instrument was removed to-day in order to have 
an alteration made, and Savigny's ring tourniquet substituted for it. 

6th. Patient not suffering any pain or inconvenience ; the sac is more 
defined, as if lined with a layer of fibrine. 

14th. Little change since last report until 5 o'clock yesterday afternoon. The 
patient stated that about that hour he was seized with nausea, succeeded by gene- 
ral tremor and clammy condition of the surface of the body. To this a sharp, 
burning pain speedily succeeded, running from the popliteal space to the 
outside of the leg. This lasted for half an hour, and then subsided. At nine 
P. M. he removed the clamp, and found that all throbbing has ceased. His 
wife, who was well acquainted with the pulsation, examined the limb as well as 
the patient himself, and was satisfied that the disease was cured. Pressure 
was accordingly discontinued, and at eleven o'clock he fell asleep. On 
awaking at six this morning, the throbbing had returned, and when visited at 
noon the pulsation of the sac was as strong as on the day before ; a vessel of 
large size, however, could be distinctly felt running over the centre of the 
tumour behind.^ Compression reapplied as before. 

20th. Pulsation becoming daily more feeble ; bruit now scarcely to be 
heard. 

26th. The sac decreasing rapidly in size, not being larger than a walnut, 
with very slight pulsation in it. 



1849.] Surgery. 231 

January 6th. No bruit, "but a single click still to be heard by the stetho- 
scope ; the tumour now so small as to fit into the bell of the instrument. 
Allowed to leave his bed, continuing the pressure. 

9th. Sac solid; at twelve o'clock a general sensation of faintness came over 
the patient, which was succeeded by burning pain in the tumour and down the 
outside of the leg ; on its diminishing, he fell asleep, and on awaking, all pulsa- 
tion had ceased. 

10th. Leg rather cold ; no other feeling of uneasiness ; one large vessel 
running over the centre of the tumour, and another on the inside of the knee. 
Pressure was continued, and the leg bandaged with flannel. 

11th. Pressure discontinued ; patient allowed to walk about with the aid of 
a stick. 

February 10th. The popliteal space was examined to-day ; no sign of the 
sac now remained, excepting a small hard body about the magnitude of a 
horse bean, which lay in the course of the artery ; the temperature of the limb 
was equal to that of its fellow ; the patient had now been at his work as a 
sawyer for upwards of three weeks. 

Mr. Tufnell, in his remarks on this case, observes that " compression was put 
fairly to the test, and that its success was complete. Though the patient was a 
man of intemperate habits — though the treatment was conducted in a small 
crowded attic, with two families living in the room, and closet adjoining — 
though the management of the instrument was left in a great measure to the 
patient himself, yet a cure was accomplished in the first instance in a less 
number of days than would have been required to have prepared him for the 
operation of tying ; and in the second he was again at his labour in a period 
fully as brief as could have been anticipated from the most successful applica- 
tion of the ligature, being at the same time spared every danger attendant on it. 

"Before attempting to prove the futility of the objections which have been 
raised against the treatment of aneurism by compression, I will make a few 
remarks upon the case just detailed. The first point worthy of attention is the 
difference in the length of time occupied in the progress of cure. It may seem 
difficult to ascribe a reason why a small and recently formed sac should in the 
same individual require nearly seven times as long for its obliteration as one of 
older standing and of larger size, but I think it may be shown to depend partly 
upon the disease itself, partly on the mode of cure. 

" When an aneurismal tumour has acquired sufficient magnitude to fill the 
whole of the popliteal space, the tension of the fascia upon it has the effect of 
compressing the sac ; thereby obstructing the current of blood through the ves- 
sel itself, and causing the collateral vessels to enlarge, indirectly paves the way 
for the future cure — a condition which, I conceive, may be materially assisted 
by treatment directed to the circulating system itself. 

" The first time that this patient was under treatment, venesection was em- 
ployed at the onset with the view of diminishing the quantity of blood, and 
thereby reducing tension of the vessels. At the same time, a serious drain 
upon the intestines was established by the compound powder of jalap. The 
supply of fluid was limited to a small quantity of tea ; thirst, when present, was 
allayed by a diuretic in the form of imperial drink, and the diet was restricted 
to bread, butter, and biscuit, with a little stirabout at night; everything, in 
fact, being done with the view of diminishing the serum, and leaving the blood 
in a highly concentrated condition. In addition to these general measures, 
pressure upon the artery was maintained uninterruptedly night and day. 

"On the other hand, the second time that he came under treatment, no such 
exactions were made. His ordinary habits of living were not interfered with 
(excepting that he was forbidden the use of spirits and beer). Purgatives 
were only resorted to when constipation ensued, and pressure for the most part 
was intermitted at night. It is to this, indeed, that I mainly attribute the 
tediousness of the cure, for until the collateral circulation is well developed, so 
as to divert the blood from the main artery of the limb, its every effort will be 
to take the larger and readier course. (This enlargement of the anastomosing 
branches is visible in many instances prior to obliteration of the sac.) 

" The second time of being under treatment, the superficial vessels were 



232 Progress of the Medical Sciences. [July 

developed on the 14th day, and upon this night pulsation temporarily ceased — : 
an effect which would, I consider, have been rendered permanent, had not com- 
pression been abruptly removed. 

" The return of pulsation in this case goes far, I think, to show that the final 
obliteration of the sac is owing to the gradual filling up of the cavity with 
fibrine, and not that the lower opening of the artery becomes suddenly plugged 
by a portion of this substance which may become detached, and that coagu- 
lation consequently ensues. Were this the case, when once the vessel was 
closed pulsation could not possibly recur. I consider rather that, as soon as the 
collateral vessels are sufficiently dilated to afford free passage to the current of 
blood, too little passes through the sac to cause dilatation of it, and that the 
stream then becomes so diminished that a few hours are sufficient for the total 
solidification of its contents ; but if, prior tOA the complete obliteration of the 
cavity, pressure be altogether removed, the blood at once resumes its natural 
channel, and pulsation then returns. This should be a reason for continuing 
compression for twenty-four hours at least after the cessation of pulsation in 
the sac and an apparent cure. 

"In alluding to the enlargement of the anastomosing vessels, I may refer to 
the uniformity with which these branches become developed. In the cases 
detailed, and in every other that I have been witness to, one vessel of very con- 
siderable size has run down the centre of the tumour behind, apparently 
beneath the integuments ; a second on the inner side of the patella ; and a third 
one (less constantly felt) outwards over the head of the fibula. 

" The artery which runs down the centre of the tumour is sometimes as large 
as the radial, and is, apparently from its direct position, the main medium of 
circulation after obliteration of the trunk. Judging from the injected prepara- 
tion of limbs where the femoral artery has been tied, the vessel in question 
would appear to be the branch that accompanies the sciatic nerve [comes 
sciatici), which in cases of ligature of the femoral becomes tortuous and greatly 
enlarged; but it is so in this case, I consider, mainly, because the transmission 
of blood by the femoral 'being suddenly stopped, a corresponding increase 
is thrown upon the internal iliac and profunda. 

" Under treatment by pressure, on the contrary, the femoral artery remains 
pervious down to the very sac, and from a careful dissection of the parts con- 
nected with popliteal disease, I am inclined rather to believe that the vessel in 
question is one which (though constant) has not hitherto received a name, and 
which, arising from the posterior aspect of the popliteal artery, five inches 
above the head of the fibula, and three above the bend of the joint, gives a 
branch to the semi-membranosus and also to the biceps muscle, and then runs 
down through the centre of the space accompanying the external saphena vein. 

" By a close observation of the course of the arteries surrounding the joint, I 
am also led to conclude that the collateral branch which generally is found to 
pulsate on the inside of the patella, is not the internal articular, but a branch 
of the popliteal, given off at least an inch above it, which, instead of running 
under the tendon of the adductor magnus, between it and the bone, passes 
superficial to the tendon, immediately beneath the integument parallel and in 
company with the tendon of the gracilis muscle. There is also a third arterial 
branch, which I look upon as being closely connected with the subject of com- 
pression ; this is a vessel of considerable size, which, leaving the popliteal a 
little above the origin of the articular arteries, runs down, intimately connected, 
if not actually in the substance, of the communicans perongei nerve. It is this 
artery, I consider, that gives rise to that burning pain experienced at the period of 
cure ; the sudden distension of the vessel, and its consequent pressure on the nerve, 
causing the painful sensation so universally described," — Dublin Medical Press, 
May 16, 1849. 

38. Remarks on the Objections which have been made against the Use of Pressure 
for the Cure of Aneurism. — Mr. Tufnell, in a paper read before the Surgical 
Society of Ireland, reviews the objections which have been urged against the 
employment of compression for the cure of aneurism. "These are," he 
remarks, "that compression is painful, wearisome, and ineffectual, I will grant 



1849.] Surgery. 233 

that it may be rendered such if the mode of treatment be not thoroughly under- 
stood, or if instruments for controlling the circulation be employed which are 
not suited to the purpose, or are used with an unnecessary degree of force. In 
the first place, in adopting this treatment, it is desirable that the principle of cure 
should be fully explained to the patient, and that he should be made a willing 
party in carrying out the surgeon's designs ; that, instead of being told to keep 
up pressure upon the artery at any particular spot for a given length of time, 
he should be recommended to raise the pad directly when it begins to cause 
annoyance, taking care, of course, that before doing so compression is made on 
another portion of the vessel. 

" Pain, I may add, is often needlessly caused by not paying sufficient attention 
to the minimum amount of pressure that will control pulsation in the sac, but 
as if to make assurance doubly sure, giving two or three additional turns to the 
screw after this object has been attained. It is to the screw, indeed, that the 
suffering hitherto felt may principally be referred. Pressure in one form or 
other has, almost in every instance, been effected by its aid, and whether used 
in a greater or a less degree, it has invariably been a dead, unyielding force, 
allowing no play or contraction to the muscular fibre beneath. This, the only 
valid objection to the use of compression, has now been entirely removed by 
the apparatus of Dr. Carte, and the introduction of an elastic pressure through 
the medium of vulcanized India rubber. 

" In this instrument, the screw, as a means of compression, has been done 
away with altogether, its place being supplied by a band of vulcanized India 
rubber. The advantages it offers are immense. Whilst I have never known a 
patient to bear compression by the screw for a longer period than three hours at 
once, in the case just detailed, Dr. Carte's apparatus was worn for double 
that time, and I have known it kept on for a longer period still.- When used in 
the case of Atkins, the instrument was incomplete. It was so contrived, that 
when the pad was let down on the artery, it could only be lifted off it by 
manual force. This required the patient to raise himself to the sitting posi- 
tion, in order to obtain a purchase, and to remain so, using considerable 
muscular exertion, until the parts beneath had so far recovered their tone that 
the instrument could be reapplied. Its employment being, on this account, 
interdicted in cases where a suspicion existed of internal arterial disease, Dr. 
Carte was induced to add a male and female screw. By this simple modifica- 
tion every objection has now been removed; a few turns of the former raise the 
pad from off the vessel, whilst the latter retains it there. The infliction of pain 
by this instrument is really so slight that I am certain the strongest opponents 
to compression will, upon a trial, withdraw this charge. 

" The second objection raised to compression is, that the treatment is iveari- 
some and prolonged. This, as a general assertion, is not borne out by facts. 
There may be particular instances where the cure has been protracted to an 
unusual length ; but, taking the average of the time which has hitherto been 
consumed in the cases that have been made public, nine-and-twenty days only 
have been occupied in the progress of cure, and this, too, be it recollected, at a 
time when the treatment was in its infancy and but imperfectly understood. 
Granting, however, that nine-and-twenty days are required for the cure by 
compression, let us contrast this period with the average duration of treatment 
by the ligature and knife. 

" From the time that a patient with aneurism is admitted into hospital, until 
he is placed upon the operating table, we may, I think, safely regard it as a 
week ; from the application of the ligature to its separation, we may consider 
as sixteen days longer ; and for closure of the wound and cicatrization, we may 
reckon on seven days more, or a time, upon the whole, fully as great as that 
hitherto occupied by compression. I have taken the average of all the cases 
hitherto treated by compression, and find it to be nine-and-twenty days. Were 
I to do the same with every case where ligature has been employed, it would 
greatly exceed this time. 

" But the sweeping assertion that compression is wearisome and prolonged, ill 
accords with cases that can be adduced, where not even days but hours were 
sufficient to complete the cure. I will specify two that, within a recent period, 



234 Progress of the Medical Sciences. [July 

have come under my own observation. In the first* of these, ten hours only 
elapsed before the pulsation had ceased; and in the second,! a large femoral 
aneurism was solidified in thirty-three. This latter case is worthy of record. 
The patient was sufficiently recovered to be enabled to leave the hospital in ten 
days, and to be married within three weeks from the time pressure was first 
commenced. Can the advocates for the knife bring a parallel case to this ? 

" Lastly, the treatment by compression is said to be ineffectual. In reply, I 
would refer skeptics to the fact that, in a period of nearly four years, in all the 
hospitals of Dublin, and in private practice as well, the ligature has only been 
resorted to once, and this a case of traumatic aneurism at the bend of the arm, 
where the operation subsequently showed a high bifurcation to exist. I would, 
however, refer those who doubt to the records of this society, to the able work 
of Dr. Bellingham, and the tables of Edwards Crisp. The latter may not prove 
satisfactory to those who affirm that the treatment by compression is dangerous, 
whilst that by the ligature is easy, gentle, and safe. 

" In the work of Dr. Crisp are detailed 206 cases of femoral and popliteal 
aneurism. In 185 of these the vessel was taken up, and the result of which 
operations is shown in the following table : — j 

Died from the effects of the operation 33 

Recovered, after suffering subsequent amputation - - - 10 

Recovered, after sloughing of the sac 3 

Recovered, after mortification of the toes - - - . - 1 

Recovered, after sloughing of the integuments - 1 

Making a total of 48 

" So that more than the fourth of the cases treated by the ligature either terminated 
fatally, or were maimed for the rest of life. This, too, not occurring in the 
practice of young and inexperienced men, but to Hunter, Pott, Cline, Cooper, 
Bell, Guthrie, Lawrence, White, Brodie, Carlisle, Syme, Travers, and others of 
almost equal note. J From this analysis, therefore, so far as regards the ligature, 
the conclusion to be drawn is, that, in the generality of cases of aneurism of the 
extremities, it should be laid aside. What object is to be gained by its use that 
is not equally attained by compression ? Does its application exert any specific 
influence upon the sac ? If so, I should, for information's sake, be glad to have 
it explained, for at present my conviction is, that, as far as regards the aneu- 
rism itself, the effects of compression and the action of the ligature are identi- 
cally the same. That in both cases the direct current is arrested, and the 
impulse of the heart no longer communicated to the sac. That the blood, pre- 
viously propelled with an injurious momentum, now trickles harmlessly through 
the collateral vessels, eddying in its passage in the hollow of the tumour, and 
lining it with fibrinous layers. 

" Such I believe to be the modus operandi of cure in either case, and where 
the condition of an aneurism is such as to allow of this effect being produced 
by means of the ligature, I am certain it will equally be the result of compres- 
sion, if properly applied. 

" As to the success attendant upon the employment of compression, I will only 
add that, since the year 1843, no less than thirty-five cases have been published, 
in which the disease has been permanently cured without injury to life or limb. 
With these facts openly detailed, I consider that in the present day no surgeon 
is justified in taking up an artery for the cure of external aneurism, until com- 
pression has been tried and failed, any more than he would be in operating for 
hernia without attempting to reduce the bowel. 

"When prejudice can be overcome, and compression be as generally adopted 

* Case 23d. Dr. Bellingham on Compression. 

t Medical Press, December 1st, 1847. 

% We may also fairly infer that, in these tables, are included the majority of the cases 
which have been attended with a favourable result, and from the reluctance which many 
men have to record their unsuccessful operations, we may, I think, with equal justice 
presume that numerous fatal ones have not been detailed. 



1849.] Surgery. 235 

as it has been in this metropolis, I feel certain that the operation of tying will 
be very seldom resorted to, and I do believe that, in the words of a recent 
writer upon the subject — ' We may confidently look forward to the day when 
ligature in aneurism of the extremities will cease to hold a place in operative 
surgery, when it shall have become a matter. of professional history, a practice 
of by gone days/"* — Dublin Med. Press, May 16, 1849. 

39. Cases of Aneurism cured by Compression. — Dr. Edward Hutton has 
communicated to the Dublin Medical Press (May 16th), the two following cases 
of aneurism successfully treated by compression : — 

Case 1. — James Collins, set. 34, a farm servant, was admitted into the Rich- 
mond Hospital on the 22d of July 1848, for aneurism of the left brachial 
artery. He stated that two months previously he was bled in the left arm by 
a " country bleeder" for a pain in his chest. He remarked at the time that the 
blood spurted out to a great distance, and was of a bright red colour. There 
was much difficulty in stopping the bleeding, and the bandage was put on very 
tightly. In three days he removed it, and found that the external wound had 
healed, but beneath this he observed a small pulsating tumour. He, however, 
returned to his labour, and continued to work for about a month, when he was 
obliged to desist on account of pain and a sense of weakness in the arm. The 
tumour had begun to increase a week before this, and pulsated strongly. No 
treatment was applied until his admission into hospital : the tumour was then 
about the size of a pullet's egg, and presented the usual characters of aneurism. 
When pressure was made on the brachial artery above the tumour, it lost its 
pulsation and tension, and yielded in some degree to pressure, but did not 
wholly collapse, indicating the presence of some coagulum in the sac. The 
skin covering this was of natural colour and thickness. The radial and ulnar 
arteries pulsated distinctly at the wrist. Immediately on his admission into 
hospital, the treatment by compression was commenced. The instrument first 
used was the screw-clamp, and although the pressure was applied occasionally 
at different points in the course of the artery, and so regulated as only just to 
stop pulsation, yet he was never but once able to sustain it for four hours 
together. After using the screw-clamp in this manner at intervals for twelve 
days, with but little effect upon the tumour, it was laid aside, and Dr. Carte's 
instrument was applied ; with this the patient maintained the compression 
during six hours in succession, and made much less complaint of its applica- 
tion. At the end of this period, all pulsation had ceased, and never returned. 
The aneurismal tumour did not, however, begin either to diminish in size or to 
increase in firmness until nearly a fortnight afterwards, when these changes 
commenced. He was detained in hospital until the 19th of September. The 
tumour was then very firm, and about one-fourth smaller. Immediately on 
leaving the hospital he returned to his labour, and was actively employed in 
gathering in the harvest. In March, 1849, 1 heard from Dr. Harkan, of Elphin, 
and subsequently from the patient himself, that the tumour was very small and 
firm, that he felt no inconvenience whatever from it, and had the full use of his 
arm. 

Case 2. — Philip Dignam, set. 32, applied for advice on the 3d of January, 
1849, for an aneurism of the left popliteal artery. The tumour was about the 
size of a hen's egg, situated in the lower part of the popliteal space. It pulsated 
strongly, and presented all the usual signs of aneurism. When the femoral 
artery was compressed, the tumour became flaccid, and could be emptied of a 
considerable portion of its contents, but some solid coagulum remained. He 
stated that, about six months previously, he first felt a " stinging pain" in the 
ham ; this was occasional only, and did not prevent him from following his usual 
employment. Two months before his application for advice, he first perceived 
a tumour which was pulsating and painful, and attended with numbness and 
weakness of the leg. The tumour slowly enlarged to the size mentioned ; his 
general health was good, and he had not confined himself to his house until a 
day or two before he came under treatment. On the 3d of January, I applied 

* Porter on Aneurism. 



236 Progress of the Medical Sciences. [July 

Br. Carte's compressing apparatus. The patient was informed of the na- 
ture of his disease ; of the alternative that awaited him if the plan of com- 
pression failed ; the mode of managing this was explained to him, and he was 
exhorted to maintain the compression for six or seven hours, or longer if he 
could. He was very anxious to avoid an operation, and readily undertook the 
treatment. The next day, January 4th, the pulsation in the tumour had ceased. 
He reported that he kept up the compression seven hours and a half in succes- 
sion, and that, during the whole time of its application, no pulsation returned to 
the tumour, nor did it after the removal of the instrument. The temperature 
of the leg and foot did not appear to differ sensibly from that of the sound limb, 
but the thermometer was not applied. It was difficult to feel pulsation dis- 
tinctly in the tibial arteries of the right leg, and impossible to do so in the left. 
Perfect rest and moderate diet were enjoined. After a week, some obscure 
pulsation was perceived, not dilating the tumour, but as if the popliteal artery 
was pervious along its base. Dr. Carte's instrument was, therefore, again 
applied for three hours, after which this pulsation was no longer to be felt. 
Two arteries were traced along the surface of the tumour ; one about the size 
of the temporal, the other smaller. The case now progressed favorably, the 
tumour became very firm, and diminished in size. In less than four weeks 
from the commencement of the treatment, he returned to his employment in a 
butter crane, where he was engaged in lifting heavy weights. I hav*> since 
seen him occasionally. The tumour, when last examined, was about the size 
of a nut, and of firm consistence. The pulse in the femoral artery could be 
felt along its course to within two inches of the tumour. He was free from all 
uneasiness in the leg, and in fact was completely cured. 

BemarJcs. — Dr. Carte's application of an elastic force in the compression of 
arteries promises in a great measure materially to lessen the pain attending it, 
and thus to remove the only plausible objection to this mode of treating aneu- 
risms becoming a rule of surgical practice. In the first case related, the patient 
was very sensitive to pain, and had not fortitude to endure the screw-clamp for 
the requisite period ; while he was able to sustain the elastic force for six hours 
without shifting the instrument from the artery, and this period proved 
sufficient for his ultimate cure. In the second case, the compression was 
maintained during seven hours and a half without relaxation, which I am per- 
suaded coiild not have been borne with the screw clamp. 



OPHTHALMOLOGY. 

40. On Inflammation of the Eye from Injury. By Dr. Jacob. — [We commend 
to the attention of our readers the following important practical remarks on 
inflammation of the eye from injury, read to the Surgical Society of Ireland 
by one of the soundest and most judicious ophthalmic surgeons of our day, 
Prof. Jacob, of Dublin.] 

" Practitioners appear to think that all injuries of the eye are to be similarly 
treated, and that nothing more is necessary than to proportion the treatment to 
the amount of injury : they seem to assume that in all cases depletion, purga- 
tives, denial of food, antimonials, mercury, and other usual remedies, are to 
be adopted, and that all they have to do is to consider the amount or extent to 
which they should be carried. This is a great mistake, for the destructive pro- 
cesses of inflammation are in many cases greatly disproportioned to the injury 
sustained : a scratch or puncture of the cornea will often cause destruction of 
the entire eye, while an extensive wound, even with laceration and contusion, 
will sometimes be repaired without extension of the consequent inflammation 
to the parts untouched. So far from considering inflammation of the eye, when 
caused by injury, to be of more simple, uncomplicated, or uniform character, 
I look upon it to be the inflammation which affords most frequently examples 
of peculiar modification or specific peculiarity. It will be intense in its nature, 
and rapid in its effects, or languid in its action, and slow or chronic in its pro- 
gress : or it will assume the rheumatic, neuralgic, or scrofulous character ; and 



1849.] Ophthalmology. 237 

even when latent syphilis is present in the system, it may be influenced by that 
poisonous influence. This may appear to some an assumption unsustained by 
facts, but of its truth I entertain no doubts : I have too often seen these modi- 
fications of inflammation following accidental injuries and operations, to be at 
all undecided on the subject. Even what may be considered the extreme case 
amongst them, the syphilitic species, I am convinced, sometimes occurs ; be- 
cause I have so often seen true syphilitic iritis attributed by patients to slight 
accidents, and I believe on just grounds, that I cannot but admit the possibility 
at least, of such combination. Indeed, the question may be fairly mooted, 
whether syphilitic iritis may not be in all cases an inflammation from ordinary 
causes modified by the'constitutional syphilitic diathesis, rather than a local con- 
centration of the disease displaying its distinct and peculiar specific characters. 
This is, however, a speculation not to be dwelt upon here, and I have therefore 
to return to the subject more immediately under consideration, the nature, 
amount, and consequences of inflammation caused by injury. The first ques- 
tion to be determined in this inquiry may appear to some a novel one, and yet 
it is one which should be settled. Is inflammation a necessary and inevitable 
consequence of injury of the eye ? That it follows from contused and lacerated 
wounds, or deeply penetrating punctures, must be admitted ; but that it always 
follows simple incised wounds, remains to be proved. We are, I believe, indebted 
to the late Dr. Macartney for suggesting this question to surgeons with refer- 
ence to injuries in general, in his work on Inflammation ; and I am satisfied of 
the correctness of his views from observations of injuries of this organ. This 
inquiry, however, cannot be entertained here : it is sufficient for the present 
purpose, to assume that practitioners not only no longer consider some inflam- 
mation necessary for the reparation of injury, but that they consider it neces- 
sary to adopt every measure and precaution to prevent or arrest that process. 
Not only have they arrived at this conclusion, but in my opinion, they proceed 
under an exaggerated notion of its importance. They appear to think, as I 
have already said, that every wound of the eye, however slight, demands what 
is called active treatment, and that severer injuries require extraordinary mea- 
sures. According to my experience, wounds of the eye are followed, either by 
no inflammation ; by suppuration, if it is the cornea which is injured ; by com- 
mon or ordinary inflammation ; or by a slow disorganizing species of inflam- 
matory action, sometimes modified by rheumatism or scrofula, or other consti- 
tutional disease. 

"When the cornea is punctured, as it sometimes is, by a needle, the prong 
of a fork, an awl, or a thorn ; or when it is cut by the point of a penknife, 
broken glass, or fragments of stone or metal, the surgeon has nothing to do in 
the way of manual operation ; but if the wound be large, and especially if it 
be a lacerated one, and extending through the iris, or allowing that membrane 
to prolapse, he has then to adjust the divided edges with a blunt probe, or the 
instrument called a curette, and to replace the iris, if possible, by gently press- 
ing it back. Having done this, he should consider what means he has at his 
disposal in the way of local application to prevent or allay inflammatory action. 
The eye is, I believe, in such cases generally bandaged up, with or without 
what is called, and perhaps appropriately, a " compress," wetted with some 
lotion. This is bad practice. The surgeon has two objects to attain by his 
dressing : to prevent mechanical irritation by friction of the lids, and to keep 
the parts cool by evaporation. To effect this, a single layer of soft old linen 
wetted with cold water, is all that is necessary ; but if the patient be obliged 
to move about and to attend to business, it is not easy to make such an appli- 
cation without pressure. I use an oval piece of old linen sufficiently large to 
cover the parts from above the eyebrow to the cheek, secured with strings of 
tape, and direct the patient to keep it constantly wet, by squeezing a sponge or 
rag clipped in cold water over it. With working men, who are generally the 
subjects of such accidents, I am, however, often obliged to sacrifice the advan- 
tage to be derived from evaporation, in consequence of their being unable to 
keep the linen wet, and am compelled to rely on the mere interruption of motion 
of the lids, with the relaxation of surface secured by moisture. With this 
view, a scrap of oiled silk lined with old linen, and wetted when it becomes 
No. XXXV.— July, 1849. 16 



238 Progress of the Medical Sciences. [July 

dry, is substituted for the evaporating application. In greater injuries of the 
eye, more precautions must be adopted. When the cornea is extensively 
divided, with or without division or prolapse of the iris or injury of the lens, 
the local treatment must be the same as that employed after the extraction of 
a cataract: both eyes must be kept closed, to prevent the separation of the lips 
of the wound by the motion of the eyelids, while temperature is to be lessened, 
or its increase retarded by water-dressing. With this view, something in the 
shape of bandage must be employed, although, from the pressure it causes, it 
is generally to be avoided. I lay one layer of old linen, about three inches 
wide, across both eyes, and instead of securing it in its place, by passing it 
round the head or pinning it to a cap, by which unequal pressure is produced, 
I have it touched at the ends with a little adhesive plaster, and by this means 
cause it to adhere to the temples, and by similar means to the forehead, just 
above the nose. This layer of old linen I direct to be constantly wetted with 
cold water where it touches the eye. After the second day, I merely cause 
scraps of wet linen to be laid over the eye, and as they become dry during sleep 
at night, I allow them to fall off at that time. If there be danger of the iris 
becoming entangled in the wound, or during the subsequent healing adhering 
to it, a belladonna lotion should be substituted for plain water, and the lids and 
brow should be painted with the extract once in twenty-four hours. If severe 
inflammation comes on, indicated by intense redness of the sclerotic and disco- 
loration of the iris ; and in cases where the cornea has been injured, accompa- 
nied by suppuration, cold-water dressing, or mere interruption of the motions 
of the eyeball and lids, will not be sufficient. Such a state is attended by 
severe pain, and demands a trial at least of warm applications in the shape of 
stupes or even poultices. These will not always relieve pain, or reduce inflam- 
matory action, but it must, I think, be admitted that they often have a soothing 
effect, and that their application is often followed by a diminution of the in- 
creased vascularity and reduction of any tumefaction which may have taken 
place. It is not easy to reconcile the theoretical explanations given of the 
effects of two such opposite agents as heat and cold, but it must be admitted 
that they are both found beneficial in the treatment of inflammation, and I 
have no doubt that they are useful in inflammation of the eye from injury or 
other cause. 

" In severe wounds of the eye, the surgeon has at first to deal with the pecu- 
liar accidents which must be found where an organ of such complicated struc- 
ture is the seat of injury ; union of the divided edges is to be secured, and a 
prolapsed iris is, as I have already observed, to be reduced ; while foreign 
bodies are to be removed, or even the lens itself, if displaced. Subsequently, 
the proximate effects or consequences of inflammation are to be encountered, 
such as abscess in the cornea, and, as I have already said, adhesions of the iris 
to the capsule of the lens. Foreign bodies should, if possible, be removed, but 
they may have been driven so deeply into the eye, or so entangled in the iris, 
that much manual and instrumental interference may be necessary. Small 
particles of iron, brass, stone, or other material sticking in the cornea, 
must be removed at once with the point of a needle ; and I am convinced that 
no needle is better suited to the purpose than that which I used for operating 
on a cataract. Larger pieces may require the use of the forceps or curette for 
their removal, and it may be necessary to follow them into the interior of the 
eye, and even to enlarge the external wound. This must, however, be done 
with great caution, as the lens, if not already injured, may be wounded, or the 
iris may be cut or torn, and the vitreous humour forced out. There may also 
be more difficulty in removing such fragments than the operator may at first 
suppose, as they may be entangled in the folds of the iris, which becomes flac- 
cid when the aqueous humour escapes, or they may be lodged in the lens or 
vitreous humour. If the crystalline lens has been wounded, and especially if 
it has been detached from its capsule, and thrown forward against the iris, or in 
front of it, it should, if possible, be removed, broken up, or depressed. It never 
should be allowed to remain in the anterior chamber, especially in aged persons, 
but should be extracted, depressed, or reclined, because it swells from imbibing 
the aqueous humour, or, if hard, remains undissolved for many months. These 



1849.] Ophthalmology. 239 

operative means of relief must, however, be employed immediately after the 
infliction of the injury, as they can scarcely he resorted to after inflammation 
has set in. 

" The local treatment of the proximate effects of inflammation following 
injury, sometimes is of considerable importance. Abscess of the cornea often 
follows slight punctures or scratches of that structure, as from foreign bodies, 
and the removal of them. The practice of opening such abscesses has been 
questioned, but in my opinion it is as necessary to give exit to matter in this 
situation, in order to prevent extension of the injury, as it is in other situations. 
Matter secreted into the chamber of the aqueous humour, if small in quantity, 
as where it constitutes hypopion, requires no opening for its escape : it will be 
absorbed sooner or later ; but if it accumulates in such quantity as to fill the 
entire chamber and to cause distension, it should be discharged. Sometimes 
when it is formed in the cornea it is diffused in its texture, but more fre- 
quently it is lodged* in a distinct cavity, and in this case, especially if large, 
it should be opened. This should be done with a keen extracting knife, and 
requires careful and delicate manipulation ; a common lancet is a very awk- 
ward instrument for the purpose. The surgeon, however, must be prepared 
for consequences apparently caused by his interference. The parts become 
so much thinned by the suppuration, that an opening takes place into the 
anterior chamber, and the iris prolapses ; but this is a consequence which 
does not cause loss of vision, unless the opening be very large, and the por- 
tion of the iris protruded very great: smaller prolapses of the iris are fol- 
lowed by irregular and eccentric pupil only. This prolapse should not be attri- 
buted to the opening of the abscess ; that operation probably often prevents this 
mischief, if done in time, or, if it does not prevent it, renders it less destructive. 
It is usual to touch the little tumour formed by this prolapsed iris with nitrate 
of silver, to reduce its size, and to allay the painful sensibility of its surface. 
This I do not consider necessary, because, when small, it shrinks to a level 
with the cornea in healing, and, when large, it is better to allow it to become 
firmly adherent to the opening through which it has passed, and somewhat con- 
solidated before interfering with it. After the inflammation has subsided, it 
may, before or after cicatrization, be punctured or even freely opened, should 
it create uneasiness or deformity from its size or prominence, which causes it 
to fall flaccid, and ultimately to contract ; it is often, however, necessary to 
repeat the puncture several times before this object is accomplished. 

" The general or constitutional treatment of inflammation of the eye from 
injury, is still more important than the local management. Destruction of the 
organ takes place either from the suppuration to which I have alluded, or from 
the inflammation extending to all its parts, and causing cataract or amaurosis, 
or both, with or without contracted and adherent pupil. The suppuration, with 
its consequent ulceration, affords a most instructive lesson to the surgeon, dis- 
playing, as it does, the influence of constitutional derangement on local inflam- 
matory action. When slight injuries of the cornea are followed by this effect, 
it is obvious that it is not the amount or extent of the wound which causes the 
greater mischief, but some condition of the system which alters the ordinary 
operations of the animal economy. Destructive ulceration or abscess is, I think, 
uniformly accompanied by obvious derangement of the digestive, assimilating, 
and nutritive functions. The tongue is white, and often even brown, in the 
centre, while the stomach is uneasy, and disturbed by flatulence and acidity. 
The fecal discharges from the alimentary canal are seldom examined in such 
cases ; but if attended to, will probably be found mixed with undigested food, 
and deficient in the colour which the bile imparts to them in a state of health ; 
the urine also affords evidence of gastric disturbance by a deposition of urates 
or uric acid. In fact, both from these symptoms, and the aspect of the patient, 
as well as from the account given of his habits and dietetic irregularities, the 
surgeon appears fully justified in assuming that the local mischief is aggra- 
vated, if not caused, by the constitutional diathesis. Abscess of the cornea, 
or secretion of purulent matter into the chamber of the aqueous humour, whe- 
ther from injury or irritable ulcer, I find almost uniformly takes place in aged 
persons, either of feeble frame, or of that turgid habit of body which indulg- 



Progress of the Medical Sciences. [July 

ence in the excesses of the table causes ; and in younger subjects who lead 
irregular lives, and are subject to great vicissitudes of diet and weather. In 
children, the same consequence is observed in those badly fed, insufficiently 
clothed, and confined to impure atmosphere ; whether in the nurseries of the 
gentry, or the close rooms and cottages of the poor. Keeping all this in view, 
the practitioner should, in my opinion, direct his attention in these cases where 
suppuration follows slight injury, to this state of the assimilating organs, rather 
than rely on depletion and mercury. I do not mean to advise that he should 
not bleed where a plethoric state of the system exists, or that he should not 
resort to mercury if the inflammation does not speedily yield ; I only wish to 
inculcate that the destructive changes in progress in the organ will be best 
arrested, by inducing a healthy state of the nutritive functions. To effect this, 
he must begin by removing the contents of the intestines by purgatives, of 
which every one has his own form of prescription. If there has been no pre- 
vious constipation, I find a dose of the compound colocynth pill, with two or 
three grains of calomel at night, followed by a purgative draught in the morn- 
ing, sufficient ; but if there should be reason to suspect that there has been for 
some time an inactive state of the alimentary canal, I keep up the purgative 
effect by giving three grains of the same pill, with one of calomel, three times 
a day, for a couple of days. The second day I commence with five grains of the 
pilula hydrargyri at night, followed by some bitter infusion, with alkali in the 
morning, and middle of the day. A mixture of infusion of quassia with about 
half an ounce of compound tincture of cardamoms, a drachm or two of aro- 
matic spirit of ammonia, and half a drachm of bicarbonate of potash, appears 
to answer the purpose in ounce doses. Nutritive food, of easy digestion, should 
be given in moderate quantity, instead of the gelatinous broths and prepara- 
tions of starch and sugar often given, and very appropriately called " slops." 
Even a small quantity of wine or other alcoholic beverage should not be de- 
nied to persons in the habit of taking them at or after dinner. All this, how- 
ever, must be done according to symptoms, state of general health, and habits. 
"Wounds or other injuries of the eye, whether accidental, or inflicted in 
operations for cataract or artificial pupil, are often followed by general inflam- 
mation of the eyeball, not very different from simple inflammation from expo- 
sure to cold, commonly called idiopathic iritis, and sometimes, as I have already 
observed, modified by constitutional disease or derangement of the nutritive 
functions. There will be the sclerotic vascularity, marginal opacity of the 
cornea, discoloration of the iris, contraction and adhesion of the pupil, cata- 
ract, and amaurosis, as in other forms of inflammation of the eyeball ; and all 
this may be varied in appearance or consequences, according to the state of the 
system at large. It may assume the scrofulous or rheumatic character, or it 
may display peculiarity of nature by its rapid progress and intensity, or by its 
slow and disorganizing operation : in fact, it differs so little in symptoms and 
consequences from the other forms, that it is unnecessary to repeat what has 
been so often stated respecting treatment. It is sufficient to observe that bleed- 
ing, diminution of food, mercury, and so much of purgative medicine as may 
be necessary, are to be made available according to circumstances, and in pro- 
portion to the activity and peculiarities of the disease ; while bark, iodine, iron, 
and other tonics and alteratives, are reserved for the subsequent stages. If 
the inflammation be of the simple or ordinary form, and the patient in good 
health, the treatment will be equally simple, and sufficiently obvious. Deple- 
tion by abstraction of blood and denial of nutritious food will, of course, be 
necessary, and should be carried into effect according to the amount of the 
injury, and the strength of the patient; but it should not be persevered in so 
as to interrupt or arrest the salutary processes of reparation. A single bleed- 
ing to lower the heart's action, and to diminish the activity of the capillary cir- 
culation, will, perhaps, be sufficient, followed by leeching in the vicinity of the 
part, if the symptoms and progress of the inflammation require it. The con- 
tents of the alimentary canal should be removed by opening medicine, but the 
continued administration of purgatives, as sometimes practised, cannot be 
necessary or beneficial. The quantity of food should be diminished, and its 
nutritious properties should, perhaps, be less than is required in a state of health, 



1849.] Ophthalmology. 241 

but it should not be composed of materials incapable of affording blood of healthy 
quality, such as any of the varieties of starch or gelatinous broths. I have 
already so often suggested the necessity of carefully adapting the administra- 
tion of mercury to the nature and intensity of the inflammation, and to the 
constitutional peculiarities of the patient, that it is unnecessary to return to 
the subject here." 

[During the discussion to which the reading of this paper gave rise, Dr. 
Jacob made some explanations, which it is important should be introduced 
here.] 

Dr. Jacob stated that, with respect to the position of the lens, and the mode of 
dealing with it when protruded, he did not think he had made himself sufficiently 
intelligible. What he desired to convey to the Society was this : that where an 
aged individual, with a hard lens, received a severe injury of the eye (say a blow 
or a lacerated wound), and that the lens lay in the anterior chamber, it was the 
duty of the surgeon to endeavour to get it out of that position, either with 
the needle or the extracting knife. He would even advise that the lens should 
not be allowed, in any case, to remain for a moment in the anterior chamber, 
whether hard or soft, as in younger subjects it immediately swelled up from 
imbibing the aqueous humour, so as to cause a terrible amount of pressure upon 
both the iris and cornea, rendering extraction indispensable. In other cases, 
however, where the protruded lens was sufficiently hard, he wished he could 
induce the profession to operate more frequently than they did ; for he could 
see no difficulty in passing the needle through the cornea, and pushing back, 
reclining, or depressing the lens, so as to place it entirely out of the way. But 
what he desired to be understood most was, that if the lens was left in the an- 
terior chamber until inflammation had set in, the bad consequences would be 
so great, that the total loss of the eye would probably follow. With reference 
to the use of depletion, he' had likewise been misunderstood ; for he never meant 
to say that where the patient was strong and plethoric, there should not be a 
copious extraction of blood. He merely stated, that where the patients suffered 
from deranged digestion, vitiated hepatic secretions, &c. &c, he thought it bet- 
ter to rely upon setting up a circulation of good blood in their bodies, so as to 
improve their general health, than to resort to the contrary practice of drain- 
ing their systems of the blood already contained in it. With reference to the 
liability of injuries of the cornea to be followed by abscess, he wished to say 
that very minute injuries and ulcers of it were sometimes succeeded by abscesses 
of a most formidable character ; but it was a mistake altogether to suppose that 
he had directed his observations, in the treatment of such abscesses, to small 
ones as well as large. His statement was, that if the anterior chamber was 
filled to distension with matter, and the abscess was large and pointing, that 
then the sooner the surgeon opened it the better: but he need hardly observe, 
that he never had been in the habit of puncturing the small collections called 
hypopion, or the patches of matter diffused or infiltrated in the structure of the 
cornea. With respect to the touching of the prolapsed iris with nitrate of silver, 
he was aware the practice was very general ; but when one person proposed a 
plan, and advocated its utility, he did not see why another individual, who 
thought he knew a still better species of practice, should not make it known. 
With reference, therefore, to the plan he advocated for the treatment of this 
condition of the iris, he would content himself with observing, that his patients 
got on at least as well under its employment, as under the use of the nitrate of 
silver. — Dub. Med. Press, Jan. 1849. 

41. Ocular Apoplexy. — In the Journal de Mtdecine et de Chirurgie Practiques, 
for January 1849, a case is recorded as having occurred in the practice of M. 
Malgaigne, at the Hopital St. Louis, in Paris, in which the patient (a little 
sweep, under treatment for fracture of the radius) was seized with dazzling 
and loss of sight. M. Malgaigne attributed this sudden blindness to apoplexy of 
the ocular nervous system, and prescribed fifteen grammes (about four drachms) 
of a compound tincture of jalap, and mustard pediluvia. In three days, sight 
was restored. 

These nervous apoplexies of the eye differ from sanguineous apoplexies, in 



242 Progress of the Medical Sciences. [July 

the absence of any obvious alteration in the appearance of the diseased organ; 
the dilated pupil alone revealing the injury. In sanguineous apoplexy, on the 
other hand, the globe of the eye presents the appearance of an effusion of blood, 
or of a scorbutic ecchymosis. M. Malgaigne has met with two or three cases 
at the Bice"tre, in which old persons in good health, and without any headache, 
were struck with blindness during the night, so that, in rising on the morning, 
they were, to their great surprise, incapable of distinguishing anything. In 
these cases, where the eye was red and somewhat painful, the blindness con- 
tinued. This result is worthy of notice, for the functions of the eye are some- 
times regained in apparently much more unfavourable conditions. As an in- 
stance of this, M. Malgaigne has seen an old man, one of whose eyes had been 
crushed without laceration of the cornea. The organ seemed entirely destroyed ; 
so much so, that the patient brought an action against the person who had in- 
jured him, and gained a verdict with damages. However, at the end of a year, 
light began to appear, and the patient finally recovered his sight. An interest- 
ing case, bearing on this point, will be found recorded at page 586 of this Jour- 
nal.— Lond. Journ. Med., June 1849. 

42. Case of Traumatic Lesion of the Globe of the Eye. — Dr. Eivatjd Landreau, 
of Lyons, relates the following remarkable case in the Gazette Me'dicale de Lyon 
for 14th February, 1849 : On the 14th of August, 1847, Madame Peyronnier, 
a portress, in endeavouring to separate two men who were fighting, received 
from one of them a blow with the fist in the left eye. The immediate conse- 
quence was abolition of vision, and the production of a swelling at the internal 
angle of the eye ; this was followed by ecchymosis of the membranes of the 
globe and of the palpebral tissues. Severe pain was at the same time felt in 
the injured organ. Medical assistance having been immediately procured, 
leeches were applied around the orbit, and cold lotions to the eye ; and an opiate 
mixture was ordered. Some days after, a purgative was administered, and a 
blister applied behind the right ear. These means having produced no relief, 
the patient consulted M. Landreau, on the 21st of the month. On examination, 
he found, at the internal angle of the eye, close to the junction of the cornea 
with the sclerotica, and very near the centre of the palpebral opening, an ovoid 
tumour, of the size of a round pea, with a reddish base, and a slightly flattened 
summit, presenting a well-marked yellowish tint. Entirely surrounding the 
base of the tumour, was a large violet-coloured ecchymosis, embracing the 
whole of the larger angle. In the anterior chamber, at its inner and lower 
part, were some drops of florid blood. The tomentum covering the anterior 
surface of the iris was dull and grayish ; and, towards the lower part, and a 
little internal to this membrane, there was a partial laceration of the iris, of 
about the size of a millimetre (about one twenty-fifth of an inch), having the 
form of a reversed V. The pupil was dilated to about double its usual dimen- 
sions, black, and perfectly immovable. Vision was destroyed, from amaurosis. 
The transparent cornea was healthy, and the deeper humours of the eye ap- 
peared to be uninjured. The sclerotic and conjunctiva, at the smaller angle, 
showed no vascular injection; the eyelids had the yellowish tint which usually 
follows bruises. The patient complained of violent pains in the injured organ, 
and in the whole of the corresponding side of the head. The tumour before 
described felt hard and resisting, but gave a sensation of slight fluctuation at 
the summit ; which, with its yellowish tint, indicated the presence of pus. M. 
Landreau, however, hesitated to open it, being uncertain as to its nature ; and, 
on attentively examining the globe of the eye, he thought he perceived the ab- 
sence of the crystalline lens, from an unusual depth of the posterior chamber, 
together with an oscillatory movement of the iris. Hence he imagined, that 
the blow on the eye might have produced rupture of some of the fibres of the 
sclerotica, and thereby occasioned an aperture sufficiently large to allow of the 
escape of the crystalline lens. It was probably, then, this latter body which 
produced the tumour under the layer of the conjunctiva. Acting on this hy- 
pothesis, he made a small opening over the tumour with a cataract knife. A 
drop of pus escaped, and he drew out at the end of his instrument a body, 
which he recognized as the crystalline lens, in an entire state. The tumour 



1849.] Midwifery. 243 

immediately disappeared ; and there only remained some puffiness of the con- 
junctiva. The eye was ordered to "be kept wet with cold lotions, and a purga- 
tive to "be taken the next day. The patient was completely free from pain at 
the end of forty-eight hours, and there was little or no consecutive inflamma- 
tion. The ecchymosis followed the usual course ; and, in about eight days, all 
traces of it, or of inflammation, had disappeared. 

The permanent effects of the injury have been perfect immobility of the pupil, 
and mydriasis, both resulting from the injury of the iris, which has resisted 
all means tried to remedy it. The laceration still exists, but is somewhat 
smaller. The retina has, under the influence of stimulant remedies, so far re- 
covered its power as to enable the patient to see with the aid of cataract 
glasses. 

M. Landreau explains the phenomena of this case by supposing, that the 
blow on the eye was perpendicular, and in a direction from the temple towards 
the nose. Its immediate effect was the violent compression of the globe, and 
the crushing of the humours from without inwards. The sclerotic at the inner 
angle was forcibly compressed against the bony floor of the orbit, and its fibres 
were thereby distended and torn. Then the crystalline lens, violently detached 
from its suspensory ligaments, was forced through the laceration in the sclero- 
tica ; and, by the motion of return of the humours from their state of compres- 
sion, was lodged under the conjunctival membrane. The violence of the blow 
also explains, in a very natural manner, the rupture of the ciliary attachments 
of the lower part of the iris, and the partial laceration of that membrane. The 
effusion of blood in the anterior chamber no doubt arose from the rupture of 
some of the vessels of the iris, when it was lacerated. It is also evident that 
the instantaneous paralysis of the retina, and the mydriasis, were effects of the 
compression and of the blow. There are two remarkable circumstances in this 
case : first, the absence of acute ophthalmitis, either external or internal ; and 
secondly, the complete restoration of the function of the retina, after such a 
sudden and complete amaurosis. — Ibid. 



MIDWIFERY. 

43. Iodine in Congestion and Erosion of the Cervix Uteri. — Dr. Churchill, 
in a communication to the Dublin Obstetrical Society, stated, that after the 
elaborate work of Dr. Bennett, and the excellent paper of Dr. Evory Kennedy, 
it would be superfluous for him to enter into a description of congestion and 
erosion of the cervix uteri. He quite agreed with those writers as to its being 
much more frequent than was heretofore believed, and, also, that it is neither 
easily detected nor easily cured without the use of the speculum. At the 
same time, he thinks it neither necessary nor becoming to propose an 
examination with this instrument in every case of vaginal discharge ; a degree 
of delicacy and discrimination should always be exercised. This is particularly 
necessary with nervous women. The author has known irremediable mischief 
result from neglecting this consideration. Again, if it be possible to avoid 
it, he should consider it wrong to propose an internal examination to an 
unmarried female. In accordance with these views, whenever he is consulted 
for a whitish or yellowish vaginal discharge, or for leucorrhoea, Dr. Churchill 
always makes an attempt to cure it by general means, such as blisters to the 
sacrum, balsam of copaiba, ergot of rye, &c, with local baths of cold water or 
astringents. Many cases are thus cured ; but if he fail, he thinks it fair to 
assume that there is either congestion or erosion, requiring other local treat- 
ment, and in the majority of cases he has found this to be so. The usual 
application is nitrate of silver, acid nitrate of mercury, nitric acid, chloride of 
zinc, all of which he has repeatedly tried with great benefit ; but it occurred to 
him (Dr. Churchill) that caustic iodine would probably answer better than any 
of these singly, inasmuch as it possesses sufficiently strong caustic properties, 
and, in addition, would be likely to act beneficially in reducing the enlarged 
cervix. The preparation Dr. Churchill employs is of the following strength: 



244 Progress of the Medical Sciences. [July 

R. — Iodinii 3jj, potassae hydriodatis §ij, aquae destillatae ^ ij, spiritus vini ^ij, 
and, after four or five years' trial, he can truly say that he has found it the best 
application for congestion, erosion, or superficial ulceration, of all that he has 
tried. Dr. Churchill usually commences with a single application of nitric 
acid, or the acid nitrate of mercury, and then, after a few days, he paints the 
entire cervex with the iodine. This must be repeated once or twice a week, but 
not oftener ; for whenever he has attempted its more frequent use, he has found 
the uterine irritation rather to increase than diminish ; and this will probably 
explain why these trifling complaints take so long a time to cure. Dr. 
Churchill had seldom succeeded in less than two months if the congestion was 
considerable, and many cases have required a much longer time. The applica- 
tion occasions no pain at all, unless the orifice of the vagina should be touched 
by the caustic, which may happen if it be applied too profusely. In one case 
the patient complained of a metallic taste in her mouth, in five minutes or less 
after each operation. After one or two applications, the cervix will generally 
be found to have diminished in volume, to have lost its tenderness, and the 
eroded surface to have lessened in extent, and to have assumed a more healthy 
appearance. Dr. Churchill strongly recommends that the application of the 
iodine should not cease abruptly, but first be diminished in frequency, then left 
off, and resumed if, as is very common, any of the symptoms return. — Medical 
Times, May 19, 1849. 

44. Tincture of Indian Hemp in Sanguineous Uterine Discharges. — Dr. 
Churchill is indebted for the knowledge of the utility of this medicine to Dr. 
Maguire, of Castleknack, who had discovered its value in this class of cases by 
accident. Dr. Maguire had prescribed a small dose of the tincture of Indian 
hemp for a poor woman laboring under some form of neuralgia ; and on 
inquiring into the effects, a few days afterwards, the patient declared that it 
had cured both her complaints ; and then, for the first time, informed Dr. 
Maguire that she had been suffering from monorrhagia. This led him to try it 
in some similar cases, and finding equally satisfactory results, he mentioned 
the fact to Dr. Churchill, requesting him to try it, which he has done exten- 
sively. Dr. Churchill mentioned it to the late Dr.'Hunt and other friends, and 
the remedy, he believes, has had a pretty fair trial ; and if their experience (as 
he believes) confirms his, the profession has reason to congratulate itself upon 
the addition of a most valuable remedy for a class of diseases whose materia 
medica has been hitherto very limited. The largest class of cases in which Dr. 
Churchill has found the most unqualified benefit are those of menorrhagia, 
where the discharge, though excessive, is fluid, and but little mixed with clots, 
and when the uterus is not enlarged. In many such cases, five drops of the 
tincture, throe times a day, have stopped the discharge in 24 or 48 hours. 
When there is pain, too, if it be not excessive, relief is obtained without the 
addition of another anodyne. In other cases, when the discharge, whether too 
much or not, has returned too frequently, Dr. Churchill has succeeded in 
arresting or postponing it to the proper period by the tincture, just as can be 
done by means of ergot of rye. In those cases of menorrhagia, when the 
uterus is much congested and enlarged, and where the discharge is largely 
mixed with coagula, although it has succeeded in many cases, yet it has 
failed in other instances, and the success in some has been incomplete. 
Nevertheless, even in these, it is of great value ; and finding that it possessed 
power even over uterine hemorrhage, it occurred to Dr. Churchill to try it in 
threatened abortion at an early period of the attack, when the hemorrhage was 
slight, and the pains rare and weak. In such cases, ergot of rye is out of the 
question ; lead has but little power. Opium, and cold applications, and quiet, 
are our principal remedies, but they often fail ; and, therefore, the addition of 
a direct and powerful agent, which should combine an astringent with an 
anodyne, would be a valuable acquisition. Dr. Churchill has now tried it in 
six or seven such cases, and he has found that, when employed sufficiently 
early, it succeeded remarkably well, but that at a later period it failed partially 
or wholly. Lastly, Dr. Churchill has tried it in three cases of cancer, at a 
tolerably early period. He gave it on account of continued draining of blood, 



1849.] Midwifery. 245 

not to any great amount, and thought that perhaps its anodyne quality might 
to a certain extent supersede the use of opium. He does not think that these 
cases are sufficient for any definite conclusion as to its value ; but the results 
will certainly induce him to repeat the trial. He does not for a moment 
suppose that it or anything else will permanently arrest the downward course 
of cancer, or that the hemorrhage will not return; but every degree of 
success, however temporary, every relief, even though slight, is of great value 
in these cases. Dr. Churchill does not pretend to explain its modus operandi; 
he can only say, that it appears to exert an astringent power in hemorrhages 
from mucous surfaces, and, also, to have a sedative or anodyne effect. The 
preparation he has invariably used is Mr. Donovan's tincture of the resin. He 
begins with five drops three times a day, in a few cases increasing it to ten, but 
seldom more. The effects are very soon seen, generally in twenty-four or 
forty-eight hours, often much sooner ; nay, in some cases mentioned to Dr. 
Churchill by Dr. Hunt and Dr. Maguire, the effect was instantaneous. In 
some cases, the beneficial effect was accompanied by a slightly unpleasant 
feeling in the head, resembling that from an extra glass of wine. In one case 
only has Dr. Churchill seen any more disagreeable results ; but in that, five 
drops produced an extraordinary degree of nervousness and a sense of sinking, 
almost of dying, which gradually passed off. — Ibid. 

45. Absence of Urea in the Liquor Amnii and Fcetal Urine. — Dr. A. H. McClin- 
tock was led to the present investigation by the examination of a foetus born at 
the full time, and which had died immediately after its birth. The vesical 
extremities of both the ureters were imperforate, and the ureter on the right 
side was so dilated as to contain not less than a pint and a half of urine. This 
case, though not unique, shows (in opposition to the generally received opinion) 
that the secretion of urine is already commenced before the birth of the infant. 
Similar cases are described by Dr. Lee, Dr. Fearns, and Dr. Montgomery. 

The researches and experiments of Drs. Prout and Bostock, of Frommhertz 
and Gugert, and of Dr. Kees, would lead us to believe, that in some cases a 
small quantity of urea is, sometimes at least, contained in the liquor amnii. 
But this evidence is more than counterbalanced by the researches of Berzelius, 
Kaspail, Mack, Colberg, Veigt, Prout, Lassaigne, and Moore, all of whom agree 
in thinking that no urea is normally contained in the liquor amnii. 

Here, then, are two classes of facts, seemingly in opposition to one another ; 
viz. first, the undoubted proofs of urine being secreted by the foetus in consider- 
able quantity before birth ; and secondly, the complete absence of urea in the 
majority of instances where the liquor amnii was subjected to accurate chemi- 
cal analysis. In order to reconcile these discordant conclusions, it becomes 
an object of the utmost importance to ascertain the composition of the foetal 
urine, as, hitherto, observers appear to have taken it for granted, that the renal 
secretion possessed the same chemical characters during intra-uterine life, as it 
does after birth. 

Further experiments by Dr. Moore seem to justify the conclusion, that the 
urine of the child before birth differs in its chemical constitution from that 
secreted subsequently, in two very remarkable particulars, viz. first, in contain- 
ing a large quantity of albumen ; and secondly, in being almost or altogether 
deficient in urea. Hence, none is to be looked for in the liquor amnii, although 
it is in all probability mixed with a large quantity of urine passed by the foetus 
during its intra-uterine life. 

The liquor allantoidis of some of the lower animals, the cow for example, is 
considered to be the urine of the foetus ; but although it has several times been 
the subject of chemical investigation, urea has not as yet been detected in it, and 
albumen has always been found present. This would seem to give additional 
confirmation to the results we have obtained in our examinations of the foetal 
urine of the human subject. According to the views of Liebig, the peculiar 
substance called allantoin appears to replace both urea and uric acid in the 
urine of the foetus of brutes; it would, therefore, be an interesting subject for 
further inquiry, to ascertain whether this or some analogous product be present 
in the urine of the human foetus. — Monthly Retrospect, June 1849, from Dublin 
Quarterly Journ., Feb. 1849. 



246 Progress of the Medical Sciences. [July 

46. Urethritis in the Female. — Dr. M'Clintock detailed to the Dublin Obste- 
trical Society, March 1, the histories of two cases of urethritis in females. One 
of these patients was a lady in the fourth month of her twelfth pregnancy, who 
had been suffering from this affection of the urethra for two months, and had 
tried a variety of means for its removal, prior to his seeing her. The other 
patient was a poor countrywoman, who had given birth to five children, three 
of whom were removed by craniotomy, in consequence of a large osteo-sarco- 
matous tumour within the pelvis. The symptoms in both cases were nearly 
identical, and were as follows : Intense burning pain during each act of 
micturition, accompanied with much straining and bearing down. There was 
no discharge from the vagina, nor any evidence of disease of this canal, or of the 
uterus. The urine of each, examined in the ordinary way, seemed healthy and 
free from albumen. Looking at the meatus urinarius, the mucous membrane 
of the canal was seen to be in a highly vascular and swollen condition, so as to 
form a considerable tumour at the orifice. This, when touched, was exquisitely 
sensitive. Having satisfied himself as to the pathological state of the parts, he 
commenced the treatment. In the first case, he began by trying astringent 
local applications, such as alum, zinc, and lead washes ; and these failing to 
produce any beneficial effect, anodyne lotions of various kinds were next used, 
but with no better result; lastly, he applied directly to the part a strong solu- 
tion of lunar caustic, but neither did this bring about any improvement in her 
condition. It then occurred to Dr. M'Clintock to make trial of copaiba, which 
we know exercises a very marked influence upon the mucous membranes 
generally. He accordingly commenced with three capsules of the balsam in 
the day, and increased the number to four per diem. This treatment at once 
produced the most decided improvement ; so that, after she had taken eighteen 
capsules, she was entirely freed from her torturing complaint. 

In the second case, the complaint was of six weeks' standing, and, without 
waiting to try the effects of any other remedies, he at once commenced the use 
of copaiba capsules in the manner just described, and with a like satisfactory 
result, as a perfect cure was established before she had finished the contents of 
the box. A subsequent examination of the urethra, showed that it had re-ac- 
quired its natural healthy characters. In commenting upon these cases, Dr. 
M'Clintock very clearly pointed out how they differed in their symptoms and 
pathological nature from gonorrhoea, from vascular tumour of the meatus uri- 
narius, and from thickening of the cellular tissue surrounding the urethra — a 
disease first described by Sir C. M. Clarke. Lastly, he alluded to Dr. AshwelFs 
chapter on "Chronic Urethritis," in the last edition of his treatise on female 
complaints, which is the first work containing a description of it. The ex- 
tremely incontrollable nature of the disease described by Dr. Ashwell, which 
almost set any treatment at defiance, inclined Dr. M'Clintock to entertain sus- 
picions as to whether the cases he met with could have been of the same nature 
as his ; and yet, that they really were instances of inflammation of the urethra, 
he established beyond any manner of doubt. In order to reconcile these con- 
flicting results, he could only suppose that the form of the complaint seen by 
him was of a milder and more tractable nature than had come under Dr. Ash- 
well's care ; or else that the inflammation had been limited to a part of the 
canal only. 

Up to the present time, both the above patients have continued in excellent 
health, and had no return of their truly painful malady. — Med. Times, March 
10, 1849. 

47. Puerperal Tetanus. — According to Dr. Pirre-Aubinais, there exists a 
traumatic puerperal affection distinct from what is ordinarily called puerperal 
eclampsia. It is characterized by clenching of the jaws (trismus), difficulty or 
utter incapability of swallowing, contraction or convulsive tension of certain of 
the muscles, and sometimes of all the voluntary muscles together. This rare 
affection it is proposed to call puerperal tetanus. It comes on spontaneously, 
generally soon after the supervention of the milk flow, and in women who 
ought not to nurse. M. Aubinais has observed it only in women in the country, 
and where the lochise, as well as the cutaneous transpiration, have been arrested 



1849.] Midwifery. 247 

by the sudden influence of cold and damps — as by plunging the feet into cold 
water, walking barefoot on damp ground, or swallowing at once a large quan- 
tity of cold water. 

Of three cases which M. Aubinais has seen, the affection proved fatal in one. 
The treatment resorted to, consisted in the use of antiphlogistic remedies and 
narcotics. In one of the cases, where the woman appeared to be under the 
influence of the poison of ague, quinine was exhibited with advantage. — Month. 
Retrospect, June 1849, from Journ. de la Societede Midecine de la Loire Inferieur. 

48. Expulsion of a Bag of Waters before the Rupture of the Membranes. — 
Dr. Alexander Wood narrated to the Edinburgh Obstetric Society (Feb. 14, 
1849) a case which had lately occurred in his practice. On the 8th of February 
he received a hasty summons to attend a patient whose accouchement was not 
expected for a month, but who was suffering from a severe attack of pneumonia. 
Labour pains had lasted about two hours before he saw her. It was her fifth 
pregnancy. On making an examination, he discovered a membranous sac pro- 
truding from between the labia, which he thought consisted of the membranes. 
On pressing this up, however, during the interval between the pains, he could 
not reach the head on account of the interposition of fluid, which could not be 
removed by pressure. The next pain expelled this membranous body, when 
it was found to present a pyriform appearance, ending in a long neck, the ex- 
tremity of which could not be reached by the finger. A double ligature was 
applied to the neck, which, being severed between the ligatures, the sac was 
removed entire, with the fluid which it contained. 

In size, it was capable of holding about six ounces of fluid. It burst in 
handling it, and discharged a clear, limpid fluid. The membranes were found 
at the next examination presenting as usual, and the case terminated naturally, 
about an hour after the expulsion of the sac. 

Both mother and child did well, although the latter was small and weakly. — ■ 
Monthly Journal, June 1849. 

49. Twins born at an interval of twenty-one days. — A woman, 35 years of age, 
was confined on the night of the 30th of March, 1848. The placenta came away 
without difficulty. The size of the abdomen remained very considerable ; the 
lochia did not flow, and, nevertheless, the surgeon did not conceive the possi- 
bility of another child. 

Dr. Prival, of Beclarrieux, was called in, and at once ascertained the pre- 
sence of a second child. The one already born was full-sized, healthy, and took 
the breast with avidity. The mother would not remain in bed ; she arose and 
occupied herself with her usual household cares. Twenty-one days after the 
birth of the first child, labour-pains again came on, and another child was born, 
as strong and healthy as the first. — Med. Times, May 26, from Union Medicate, 
May 17, 1849. 

50. Case in which the Liquor Amnii and the Meconium ivere both bloody. — Dr. 
Moir communicated to the Edinburgh Obstetric Society (Jan. 10, 1849) the fol- 
lowing case : In July 1848, a lady, then at her full period of pregnancy, had 
suddenly and without warning a discharge of fluid per vaginum, so copious as to 
run in a stream along the floor, after passing through her clothes and the chair 
on which she was sitting. From its colour it was supposed to be blood ; she 
was consequently put to bed, and Dr. M.'s immediate presence was requested. 
On his arrival, he found that during each pain there was a gush of dark, bloody- 
coloured fluid, but as it did not coagulate, and as the pulse was not affected, he 
inferred that it was the result of some abnormal state of the liquor amnii, and 
therefore allowed the case to go on without interference. In about an hour a 
full-sized, healthy female child was born. The placenta, which still continued 
attached at the time of birth, soon separated, and appeared to be perfectly 
healthy. 

Previous to the infant's being finally separated from the mother, it passed 
some meconium, and Dr. M. was surprised on observing that it was of a very 
dark red colour, and that on being wiped off the sheets it left a reddish stain, 



248 Progress of the Medical Sciences. [July 

On paying his visit next morning, the nurse, in great alarm, showed him several 
cloths containing meconium of the same appearance, but as the child seemed in 
every other respect healthy, nothing was administered but a small teaspoonful 
of castor oil, which brought off a good deal more during the day and evening. 
Next day the stools gradually assumed a healthy appearance, and have con- 
tinued so. The child is healthy and well. 

The first question that suggests itself in this case is — Whence the bloody 
liquor amnii? Was it from the intestines of the child, or from the uterus, or 
its membranes ? Most probably it was from the latter, because, had it been 
from the child, we should have had some appearance of blood in the stools after 
the whole of the meconium was discharged ; but there was none. But in his 
opinion the most interesting question, in a physiological point of view, is — 
Whence the bloody meconium ? because, if correct in the former supposition, 
the foetus in utero must have swallowed the bloody liquor amnii, and this must 
have undergone the process of digestion. Are we therefore to infer, that the 
liquor amnii is always or occasionally one of the sources from which the foetus 
derives nourishment. The general opinion hitherto has been, that it does not, 
but the present case seems to favor the conclusion that it does. — Monthly Jour- 
nal, April 1849. 

51. On Prolapsus Uteri. — Professor Hohl believes that some very erroneous 
notions prevail as to the causes of this occurrence, and that some light may be 
thrown upon the subject by considering the changes of position which the 
uterus normally undergoes at different periods of life. In the mature foetus, 
the uterus projects considerably beyond the pelvis : and it is only when it has 
acquired its completed shape and size at puberty, that it is found entirely 
within the cavity. At the commencement of the menstrual cycle it retains its 
position, or even rises still higher in the pelvis, while at the termination of this 
it again sinks, with the loss of blood, in stout young women. In women who 
seldom or never bear children it sinks still deeper, as it does too, after the men- 
stral functions have ceased. In pregnancy the organ rises remarkably, and M. 
Hohl denies the correctness of the statement that it sinks lower in the pelvis 
after the second month, the apparent sinking being due to the turgescence of 
the organ, and especially of its cervix. After delivery the uterus remains high 
up in the abdomen, and only gradually resumes its ordinary position. In old 
women it is found deep in the pelvis. 

The production of prolapsus is not dependent upon the condition of the 
vagina, and the ligaments of the uterus. The vital power of the organ may be 
said to maintain it in position. When this is augmented the uterus is raised, 
while, when it is diminished or lost, it descends. Other organs, and indeed 
the whole body, in like manner exhibit strength and power proportionate to their 
turgor vitalis. The increase of the vital activity of the uterus during its develop- 
ment and growth, as also during menstruation and in pregnancy, is attended 
with elevation of the organ, which sinks again when these conditions prevail no 
longer. So far from allowing that the prolapse results from defective support- 
ing power of the vagina, we may rather regard the uterus as supporting the 
vagina, and prolapsus of the latter may occur without any prolapsus uteri. 

Thus the author refers the production of, prolapsus to a preceding or co-exist- 
ing condition of health, giving rise to a diminished vitality. This explains why 
we so seldom meet with the disease in young healthy women ; while we know 
that whatever favours the relaxation of the genital system, and lowers the tone 
of the fibre, acts predisposingly — the germ of the evil being found in the puer- 
peral condition, when the uterus, after having been high up in the abdomen, 
sinks down into the lesser pelvis. 

Although prolapsus may be secondarily produced by other affections, as tumours 
of the belly, prolapsus vaginae, cystocele, &c. &c, yet far more frequently a 
change in the direction, rather than in the position of the organ then takes 
place ; and, even while the portion of the rectum in connection with its posterior 
wall may prolapse entirely, the uterus may retain its normal position. 

There may be a diseased condition of the economy in general, or of the uterus 
in particular, upon which depends this extinction or diminution of its vital 



1849.] Midwifery. 249 

power ; and accordingly as this is or is not curable, will depend whether the 
cure of a prolapsus is apparent or real ; as mere reposition with mechanical sup- 
port is not a cure. In some diseases which are attended with an increased 
activity of the uterus, there is arising of the organ in the pelvis, as puerperal 
fever, hydrometra, &c. Disease of the ovaries does not produce any sinking of 
the organ ; nor do tumours or indurations of its substance as long as they are in 
process of development, nor until they have interrupted its functions, or weighed 
it down by their great bulk. Polypi also seldom gave rise to prolapsus. 

Treatment. Common as is the disease, a radical cure is seldom accomplished. 
The indications are to remedy the defective or disordered condition of the general 
vital powers, or of those of the uterus in particular. The author especially 
warns us against the continued use of injections, and the too early employment 
of pessaries. When the vital power of the sexual system or uterus is exhausted 
in consequence of age, over-stimulus, or incurable disease, mere palliative 
treatment should be employed. — Brit. & For. Medico- Chirur. Rev., from Zeit- 
schriftfilr Gebertskunde, Band xxiv. pp. 321-340. 

52. Case of Hydrometra occurring in an Unimpregnated Uterus. By Dr. Gran- 
didier. — This case occurred in the person of D. F., set. 21, unmarried, and of a 
scrofulous habit of body. In Nov. 1842 her menses, which had been very irregu- 
lar, were arrested, and the belly began to swell, so that in twelve weeks it re- 
sembled that of a pregnant woman in her last months. The distension was as 
equable as in ascites, but a fluctuation was only very obscurely felt. The ex- 
tremities were swollen, respiration hurried, and the amount of urine small. 
Examination, per vaginam, having proved the groundlessness of the charge of 
pregnancy, she was treated by various hydragogues, &c, as for ordinary 
ascites ; and it was not until paracentesis had been in vain attempted that a 
hydrometra was diagnosed. Ten grains of secale cornutum were now ordered 
every two hours, until uterine action was developed. Great pain and anguish 
were thus produced, which continued for twenty-four hours, when (one hundred 
and twenty grains of secale having been taken) a small plug of mucus was ex- 
pelled from the vagina, and followed by the uninterrupted flow of six maas 
(sixty-four ounces) of a clear, watery fluid. The patient's sufferings were much 
relieved ; her general condition improved ; and while taking Stahl's pills her 
menses returned. Still her belly never resumed completely its normal size, and 
at intervals, varying from one to three weeks, there were gradually expelled 
other eighteen maas of the same fluid. In June, 1843, she repaired to the sul- 
phureous waters at Nenndorf, the belly being as large as in advanced pregnancy ; 
and, the menses again disappearing, ten maas of fluid were discharged from the 
vagina. In August, seven maas ; and in September, thirty-nine were discharged ; 
but after this period, the mineral waters and other means employed having 
removed the deranged condition of the digestive organs under which she had 
long laboured, and the discharge of water, per vaginam, which had probably 
accumulated during the stasis of the venous abdominal circulation, entirely 
ceased. — Brit. & For. Medico-CMr. Rev., April 1849, from Neue Zeitschrift fur 
Geburtskunde, Band xxiv. pp. 261-8. 

53. Prolapsus of the Funis during Labour. — Dr. Hoffman does not admit the 
validity of the explanation of this occurrence, which refers it to a disproportion- 
ately large pelvis or small head. If this were the case, the accident would be 
met with far more frequently than it is, and especially during premature labours. 
He believes it to be dependent upon an irregular contraction of the uterus, 
whereby the lower segment of the organ becomes unduly relaxed. He has 
never met with it in cases in which the pains have manifested their normal 
activity, but only in those in which they have assumed a spasmodic character. 
Upon these grounds he declares the mere reposition of the funis, unless the 
character of the pains can also be changed, to be of no avail ; for the lower 
segment of the uterus not being applied to the head in these irregular pains, as 
it should be, the prolapsus is sure again to recur. 

Moreover, the reposition of the funis is opposed by a general law which, 
however easily demonstrable, the author does not recollect to have ever seen 



250 Progress of the Medical Sciences. [July 

stated. It is, that when during the progress of labour any portion of the ovum 
has quitted the cavity of the uterus, it can never be replaced. As soon as any 
of the liquor amnii is discharged, the walls of the uterus become closely applied 
to the contour of the child, and the size of its cavity pro tanto diminished. Just 
in proportion as the parts of the child quit this cavity, does its size continue 
diminishing, and neither a spontaneous nor artifical return of these is possible. 
So it is with the funis ; the cavity of the uterus having diminished in size since 
its descent, there remains no longer room for it. The general conclusion to be 
drawn is, that when the funis is prolapsed, to save the child, we must resort to 
turning, and place no reliance on the various instruments which have been con- 
trived for its replacement. — Ibid., from Ibid., Band xxv. p. 45. 

54. Spontaneous Rupture of the Uterus — Recovery. — James Church, Esq., has 
communicated to the Lancet (May 19) a case of spontaneous rupture of the 
uterus, in a corpulent woman 42 years of age, during her tenth labour, in 
which recovery took place. The rupture extended from near the fundus 
towards the left side, through which the child escaped. Mr. C. introduced his 
hand into the uterus and delivered the child, which was dead. 

55. Subacute Inflammation of the Ovaries and of the Fallopian Tubes as one of 
the Causes of Sterility. — Dr. Tilt read a paper before the Westminster Medical 
Society (April 28) on this subject. After dividing the causes of sterility into 
those which are self-evident, those which are disputable, and those which are 
of a mysterious nature, Dr. Tilt drew the attention of the Society to subacute 
ovaritis as a frequent cause of sterility. He founded this assertion — 

I. — On physiological data. 
II. — On the testimony of authors. 
III. — On the cases which he brought forward. 

He began by establishing the paramount importance of the ovaries in the 
hierarchy of our organs, showing that the anatomical phenomena of ovulation 
were identical to those termed inflammatory, and thus led us to believe that in 
morbid ovulation the healthy process might often pass into the inflammatory, 
and furnish a satisfactory explanation of the increase of pains and of heat in 
the ovarian regions — symptoms so frequently met with in difficult menstruation. 
He considered that subacute inflammation of the ovaries might produce all those 
symptoms which are called by the common name of dysmenorrhoea, although 
they may also depend on the disorder of other organs. He also admitted that 
the symptoms of subacute ovaritis might vary according to the nature of the 
patient's constitution, producing hysterical symptoms in nervous and highly 
excitable females, and morbid products and sterility in those of a strumous 
constitution. 

II. — Dr. Tilt proved, by the testimony of authors, the frequency of unac- 
counted-for ovarian lesions ; and as these lesions are admitted by all to be the 
products of inflammation, he drew, as an evident conclusion, that the ovaries 
and their peritoneal covering were frequently subjected to inflammation, though 
not recognized as such during the patient's life, nor treated accordingly. In- 
specting the production of dysmenorrhoea, Dr. Tilt admitted, that in some 
instances all the symptoms of that disease were produced by subacute ovaritis, 
while in others, as it has been well established by Dr. Oldham, ovaritis deter- 
mines dysmenorrhoea by the inflammatory congestion of the uterus to which it 
gives rise ; but he did not agree with Dr. Rigby that membraniform exudations 
in the catamenia were always the proof of ovaritis. Having thus established 
that subacute ovaritis is a frequent cause of dysmenorrhoea, Dr. Tilt observed 
that dysmenorrhoea and sterility being admitted as concomitant facts, depend- 
ing on each other, or on the same cause, he had a right to infer that subacute 
ovaritis was a cause of sterility, and that this imperfection was the result — 

1. Of morbid lesions of the stroma, or of the vesicles of the ovula therein con- 
tained. 

2. Of a false membranous deposit lining the ovaries, so as to preclude the exit 
of the ovula. 



1849.] Midwifery. 251 

3. Of lesions in the tube destined to convey the ovula to their uterine abode. 
He likewise stated that sterility was sometimes produced by the uterine ex- 
tremities being blocked up by a glutinous deposit, and asked — whether there 
was any possibility of doing for these organs what Mackintosh and Simpson 
have done in similar cases of temporary occlusion of the neck of the womb. 

In concluding the enumeration of morbid lesions, Dr. Tilt remarked that as 
our physiology of the ovaries dates only from yesterday, we need not be sur- 
prised if the knowledge of their pathology is also in an embryotic state. 

III. The paper was concluded by Dr. Tilt's giving three cases in which the 
diagnosis of the disease was fully confirmed, by an accurate examination of the 
patient through the rectum, and wherein the treatment recommended brought 
on the cessation of sterility after it had lasted five, six, and seven years. The 
remedial measures prescribed were leeches, to diminish the chronic ovarian 
congestion ; blisters, to break the chain of a morbid nervous action, fostered by 
long habits of suffering ; mercurial ointment, combined with narcotic extracts 
and camphor, to reduce pain and vascular action ; and medicated enemata were 
administered with the same intention. — Lancet, May 5. 

56. Cases of Sudden Death after Delivery. — Dr. McCowan stated to the Edin- 
burgh Obstetric Society (Jan. 10), that on the 16th June, 1845, he was requested 
to visit Anne Barker, set. twenty-one, stated to be in labour with her first child. 
On his arrival, he found her suffering from spurious pains, and complaining 
much of difficulty of breathing, and pain in left sub-mammary region. The 
face was very oedematous, as also the lower extremities. Under the usual treat- 
ment the pains subsided. During the two following days she complained occa- 
sionally. 

On the 19th she had much pain in her side ; respiration laborious ; pulse, 
which had hitherto been about 70 to 80, rose to 120, but feeble. Yenesection 
to ten ounces produced faintness, without alleviating the pain. She was then 
cupped to four ounces, with immediate relief. 

About three A. M. of the 20th, labour commenced, and proceeded naturally 
and speedily till nine A. M., when she was delivered of a still-born male child, 
and instantly expired. 

Post-mortem. — The body presented a generally oedematous appearance. 

On opening the thorax, the pericardium was found distended with a dark 
fluid. The heart was much enlarged, extending about two inches to the right 
of the sternum. Right ventricle very thin and dilated. The aortic opening 
could with difficulty admit the point of the little finger ; its valves were hard 
and cartilaginous. The whole heart was filled with coagulated blood. The 
surfaces of the pleurse were strongly adherent ; the greater part of the left lung 
was hepatized. The uterus and other organs seemed healthy. 

Dr. Simpson stated that, ten or twelve years ago, when acting as resident 
house-surgeon in the Lying-in Hospital, he was called by a midwife to see a pa- 
tient who had suddenly fainted and died immediately after the expulsion of the 
infant. The uterus, as felt through the abdominal parietes, appeared firm and 
contracted. The labour had been natural, without any hemorrhage or any other 
complication. An autopsy was not obtained ; but the anterior history of the 
patient showed the probability of the existence of diseased heart. A short 
time afterwards a patient, attended by one of the pupils of the hospital, rose 
up and stood for the first time about a week after delivery. She immediately 
fainted and expired. There had been nothing particular in the history of the 
labour or convalescence. Drs. Denman, Clarke, Blundell, Meigs, &c, had re- 
corded notices of cases of this kind of sudden death during labour, or after it, 
without convulsions or hemorrhage. Dr. S. had always taught that the ex- 
istence of heart or chest disease formed a kind of complication, which was not 
only extremely anxious in itself, but that generally incapacitated the patient 
from bearing with impunity, for any great length of time, the struggles and 
efforts of a prolonged second stage. He considered such a complication an in- 
dication for earlier instrumental assistance than would be deemed necessary 
under other circumstances. — Monthly Journ., May 1849. 



252 Progress of the Medical Sciences. [July 



CHOLERA. 

57. Cholera is the topic of deepest interest at the present time. This pesti- 
lence is now prevailing over the larger portion of our country, causing in some 
places an almost incredible mortality, and nearly everywhere creating terror 
and alarm. To the medical profession, the public look for the measures best 
calculated to arrest the progress of the pestilence, and for the remedies adapted 
to lessen its fatality ; and it behooves them to devote, with untiring zeal, their 
best energies to fulfil these expectations. With the desire to assist in this labour, 
we have collected and present, in the following articles, all the late investiga- 
tions and discoveries which have been made, relative to the pathology, treat- 
ment, &c. &c, of the scourge which is now afflicting us. 

58. Pathological Appearances in Cholera. — The alterations observed by M. 
Virchow, in the intestinal canal, consist in an uniform invasion of the entire 
mucous membrane, without any special affection of the glandular apparatus. 
It is true that the solitary glands are sometimes diseased as well as those of 
Peyer, but these lesions are far from constant. The changes in the mucou3 
membrane itself are very like those of diphtheritis, commencing in intense 
hypersemia, with extravasation of blood, and the exudation of a whitish mem- 
brane. At this period the microscope exhibits an amorphous granular matter, 
interposed between the fibres of the mucous membrane, which becomes partially 
sphacelated. These changes are mostly seen at the lower end of the small 
intestine. It should be remarked that these diphtheritic appearances were not 
constant. 

The intestinal secretions sometimes contained albumen, at others only saline 
ingredients. The mesenteries were almost constantly infiltrated with a pecu- 
liar whitish granular matter. 

The author also frequently met with engorgement of the spleen, but this was 
chiefly among boatmen, many of whom had been the subjects of intermittents. 

The stomach was not remarkable for any constant morbid appearance, it was 
generally distended and intensely injected. An epithelial exfoliation was 
always seen in the duodenum, and its villi were often infiltrated with fatty 
matter. The gall-bladder always contained an abundance of bile. The liver 
was pale and exsanguine. The calices of the kidney exhibited capillary injec- 
tions, with increased epithelial secretions. The bladder was always empty, 
and closely contracted. The lungs collapsed on opening the thorax ; their in- 
ferior lobe was often engorged. In several cases the author found interlobular 
emphysema. The pleura was sometimes covered with patches of false mem- 
brane. The heart was pale, and rigidly contracted on the left side, but the 
right cavities were always gorged with dark, coagulated blood, mixed with 
fibrinous concretions, in which were globules resembling pus. The veins were 
generally gorged with black blood, while the arterial system was empty. The 
heart was always healthy. 

Such were the appearances in the algide period of cholera. In cases which 
died during the typhoid period, signs of inflammation with exudation were ob- 
served in various organs. It was at the commencement of this stage that the 
diphtheritic patches were commonly noticed, both in the intestines and in the 
vagina, especially when the patient had been seized during menstruation. The 
lungs sometimes exhibited apoplectic extravasations. In the kidney, there were 
often seen the appearances indicative of acute albuminous nephritis. — Gazette 
MM., Jan. 20th. 

59. Hypertrophy of Peyer 's Glands in Cholera. — The numerous microscopic in- 
vestigations which have lately been made in Paris, tend to establish that hyper- 
trophy of the intestinal follicles, coinciding with a protrusion of Peyer' s glands, 
and more or less vascularity, are pretty constantly found in persons who have 
died of cholera. Large ecchymoses have also been discovered in all the paren- 
chymatous organs, not only on their surface, but situated within their sub- 
stance. These ecchymoses have been found so extensive, and of so dark a 
colour, that they looked very much like gangrenous patches. — Lancet, May 1849. 



1849.] Cholera. 253 

60. On the Pathological Condition of the Blood in Cholera. — This is the title 
of an extremely interesting and valuable paper, by A. B. Garrod, M. D., con- 
tained in the London Journal of Medicine, for May last. The author divides 
the subject into two parts. The first contains an account of the results which 
were obtained during the former epidemic of cholera in Europe; the second 
treats of the analyses recently performed. 

"With regard to the first part, it will be sufficient to state the conclusions to be 
drawn from the researches formerly made, and which Dr. Garrod states to be 
as follows: — 

1. That in cholera, the physical characters of the blood are altered, and that 
its tendency is to become thicker, tar-like, and less coagulable. 

2. That the proportion of water is much diminished. 

3. That the specific gravity of the serum is very high, which is due to the 
increase of the solid portion of the serum, and especially of the albumen ; and 
that this fluid also tends to become less alkaline in its reaction. 

4. That with regard to the salts of the serum, some doubt exists as to their 
excessive diminution. 

5. That urea sometimes exists in cholera blood. 

The second part details the analyses made upon eight specimens of cholera 
blood, with an account of the cases from which the specimens were obtained. 
A table is given also showing the composition of healthy blood, the more readily 
to compare the results. 

Without entering into details, we shall give the results which Dr. Garrod has 
arrived at from his analyses, and show how far they accord with the results 
formerly obtained. 

Physical Condition of Cholera Blood. — As far as this point is concerned, 
Dr. G. observes, all recent observations agree with those formerly made, and 
indicate that, from the commencement of the disease, this fluid becomes more 
tenacious, of a darker colour, with less disposition to coagulate, and that its 
specific gravity is very greatly increased. It will be found, by reference to the 
tables giving the results of Becquerel and Rodier's examination of the blood of 
men and women, that the maximum specific gravity in the male is 1062, in the 
female 1060. Now, in our cholera cases, we have found the specific gravity in 
adult males to be, in round numbers, 1076 and 1081, and in females 1068, 1074, 
and 1076 ; also, in children under ten years of age, in whom the blood probably 
has a specific gravity not exceeding 1045, we have found it as high as 1076 in 
one case, and in the second it was doubtless even higher (for it contained more 
solid matter), although the small quantity of the blood did not allow it to be 
accurately determined. We have thus proved that, in cholera, this property of 
the blood is greatly altered. 

Water arid Solids. — Of course, the watery portions of the blood experience a 
diminution, nearly corresponding to the increase of the specific gravity of the 
fluid, and the solids a corresponding increase. In the table above referred to, 
the maximum amount of solids in males was 240, and in females 227 parts in 
the 1000 of blood ; in children it is very much less. In our cholera cases we 
have found that the numbers representing the total solids were 251, 260, 271, 
271, 275, 282, 284. 

Blood Globules. — These we have also found to be increased in quantity, in the 
case in which we have been enabled to separate them from the albumen ; and in 
place of 140 parts in the 1000 (which is considered a very high healthy average), 
we have found them to form 166 and 171 parts. 

Fibrine. — In the case (Worts), where the blood coagulated pretty firmly, 
2.61 parts of fibrine were obtained in the 1000 parts of blood ; in Dr. Parkes' 
case, 0.88 ; but I remarked that the fibrine in Worts' case, although exceeding 
in quantity the normal average (2.20), was yet much less consistent than natural 
in character. After death, the blood of this man did not coagulate at all, and 
I think it is probable that in cholera this element of the blood undergoes 
changes of quality, rather than of quantity, and that, as long as it can be ascer- 
tained correctly, analyses do not indicate any marked deficiency ; after a time, 
however, it can no longer be collected. 

Serum. — As to the specific gravity of this portion of the blood, our observa 
No. XXXV.— July, 1849. 17 



254 Progress of the Medical Sciences, [July 

tions were only two. in number, and these were obtained from the blood of the 
same patient, at different times ; both of them tend to confirm the results pre- 
viously found ; namely, that this fluid becomes much heavier, from the large 
increase in the amount of its solid constituents ; healthy serum being of specific 
gravity 1028, we found it in cholera to be 1039 and 1041. 

Albumen. — This constituent of the serum was only estimated in two cases, 
and in these amounted to about 125 parts in the 1000 parts of serum, and to 
103 parts in the 1000 of blood; so we see that it is increased in both fluids. 
This we might naturally expect, when we take into consideration the character 
of the stools in this disease ; for in them we find that, compared with some of 
the other ingredients of this fluid, the albumen is thrown out in very small pro- 
portions ; and although the ratio between the serum and clot is diminished, yet 
the decrease in the water more than counterbalances the loss which the albumen 
sustains. 

Salts of the Blood and Serum. — On this point our results have far from ac- 
corded with those obtained by Dr. O'Shaughnessy, and upon which so much 
stress has been frequently laid ; we will therefore dwell a short time to consider 
the facts which have been elicited. Becquerel and Rodier found that the max- 
imum amount of soluble salts in the 1000 parts of blood was, in the male 7.4, 
the minimum 4.3, the mean 5.6 parts ; in the female, maximum 7.0, minimum 
6.0, and mean 6.8 parts. We have found in our cholera cases, that, where the 
soluble salts were separately estimated, they were represented by the numbers 
10.7, 7.54, 7.5, 6.15, 6.02, and 5.72 parts in the 1000 parts of blood; every 
number exceeding the mean, and many the maximums obtained by Becquerel 
and Rodier from the healthy blood both of males and females. The analyses 
were performed in the same way. Again, with regard to serum in health, in 
Lecanu's standard we find 8.1 parts in 1000; in a specimen of healthy serum 
(analyzed by myself for the purpose of comparison), 9.34 parts, and in Bec- 
querel and Rodier's table, when estimated in 1000 parts of serum, from about 
6 to 8 parts. In the serum of cholera, we observe 8.12 and 7.43 parts ; in neither 
case less than the mean of numerous analyses of healthy serum ; and it should 
be borne in mind that, when the specific gravity of the fluid is high, from the 
increase of the albumen, as happens in cholera, the estimation of the salts in 
the 1000 parts of serum or blood is scarcely correct (for we should rather find 
the ratio existing between the water and soluble salts) : if this is done, then, 
from our experiments, the amount of salts, instead of being decreased, as sup- 
posed by Dr. O'Shaughnessy, will b'e found always increased. It is curious to 
remark the composition of the blood in Cases I. and II.; the subjects were 
children under ten years of age, in whom the disease proved rapidly fatal. In 
both specimens of blood, the soluble salts were very greatly increased ; in that 
from the younger child, they were nearly twice the amount found in health. I 
should have been almost inclined to doubt the accuracy of these analyses, as 
they were made on very small quantities of blood, but on looking into my note 
book, every step appears to have been correctly performed : and, to confirm 
their accuracy, the third analyses made on the top portion of the blood (much 
more fluid being used in the operation), showed a still greater increase of these 
salts, due to the presence of a larger quantity of serum in a given weight of 
blood. It would have been extremely interesting to have known the composi- 
tion of the stools passed by these children, to have seen whether or not the ratio 
between the water and soluble salts was increased. In Dr. Parkes' paper on 
Intestinal Discharges in Cholera {London Journal of Medicine, No. II.), it will 
be observed, that the stools passed by children, 10 and 11 years of age, con- 
tained in the 1000 parts a smaller amount of the salts than those discharged by 
adults ; and it is possible that there may exist some difference in the mode of 
action of the poison in children and adults : a difference in the symptoms cer- 
tainly does exist. 

It has been noticed, in the cases now referred to, as well as in those spoken 
of in Part I., that the blood often became neutral, in some cases even acid. Dr. 
O'Shaughnessy considered this as depending on the blood losing its carbonate 
of soda, to the presence of which its normal alkaline reaction was referred. At 
the present time, however, the existence of this salt, even in Wealthy blood, is 



1849.] Cholera. 255 

denied by many ; and certainly many of the properties of the serum, formerly 
ascribed to it, depend on the tribasic phosphate of soda, which, when it contains 
two atoms of fixed base, possesses an alkaline reaction, and has the power of 
holding carbonic acid in solution. That this alkaline salt is not deficient, even 
when the blood shows a decided acid reaction, was clearly proved by our finding 
that the ash from such blood or serum exhibited alkaline properties, quite as 
strong as that obtained from these fluids in health. 

The nature of the acid which existed in such blood was not made out ; but 
it certainly was not volatile. Though we have found no diminution of the salts 
in the blood of cholera patients, yet, of necessity, the total amount in the 
system must be decidedly lessened, but so also is the total bulk of the blood. 

Urea. — It was stated, in our first part, that urea had been detected in the 
blood and other fluids in cholera ; but in most cases its amount was not esti- 
mated, and no relation between the quantity of this principle and the stage or 
intensity of the disease observed : to this point we paid some attention, and I 
think that the results obtained will prove interesing. In Cases II. and III. 
(Toothing children), no urea was found, and certainly it did not exist in the 
blood to any large extent. Still, from the small amount of blood examined, a 
quantity greater than in health might have escaped discovery ; and that such 
was the case, we have some evidence in the increased amount of uric acid, 
which, when suspension of the urinary excretion takes place, is found in excess 
in the blood along with the urea, and can be more easily discovered, not being 
so liable to suffer decomposition ; still the urea was not in large excess. In 
these cases, death took place during the stage of collapse. In Case III. it will 
be also observed that no urea was found, but Dr. Parkes remarks, that it may 
have been present in small quantities, but certainly not in large excess. The 
blood in Case VI. was not examined for this principle. In Case V. urea was 
sought for twice ; first, when the patient was in a state of partial collapse, 
next, in the blood obtained from the large vessels after death ; and it will be 
seen, that in the collapse stage (not intense) 1000 parts of blood contained 0.38 
part of urea; after death (partial reaction having taken place), as much as 0.92 
part was found in the same quantity of blood. In Case VI., where the blood 
was taken after death, the patient having had partial reaction, and then be- 
coming semi-comatose, 0.65 part of urea was obtained from the 1000 parts of 
blood; and, lastly, in Case VII., where reaction had been restored, and the pa- 
tient was suffering considerably from head symptoms and fever, the 1000 parts 
of the serum of the blood taken during life, yielded 1.14 parts of urea. So we 
find that the urea gradually increases in amount, from the cold stage to that of 
febrile reaction. The explanation of this phenomenon is, I think, exceedingly 
simple ; for I should imagine that, in intense and sudden collapse, not only is 
the function of the urinary excreting organ diminished or suppressed, but also 
the vital metamorphoses, and therefore the formation of urea, are likewise 
nearly suspended. This would account for the small amount usually found 
in the collapse, and probably the quantity varies inversely with the intensity 
of this state ; but when partial reaction ensues, and the vital changes take 
place with greater activity, should the function of the kidneys not be at the 
same time restored, urea must accumulate in the blood, and the amount must 
depend on the degree of the reaction (febrile or not), and the extent of sup- 
pression of the urinary secretion. This view is certainly supported by the re- 
sults which have been as yet obtained, not only recently by ourselves, but also 
in the former epidemic by Dr. O'Shaughnessy and others. 

Conclusions. — In comparing the recent analyses with those given in the first 
part of the paper, it will be seen that, as far as concerns the physical pro- 
perties of the blood, the diminished amount of water, and the consequent in- 
crease of the solid portion, also the high specific gravity of the serum, and its 
tendency to become less alkaline, our own conclusions perfectly agree with those 
previously made ; and therefore, that conclusions 1, 2, and 3, before given, are 
thus far confirmed. With regard to (4) and (5), concerning the salts and urea, 
our conclusions must be — 

4. That in cholera, the saline constituents of the blood are not only not de- 
creased in amount, but sometimes exist even in increased proportion, and that 



256 



Progress of the Medical Sciences. 



[July 



the diminution of its alkaline reaction is not due to the loss of salts, but to 
the impeded excretion of organic acids, which are constantly being formed in 
the system. 

5. That urea usually exists in increased quantities in cholera blood, but that 
the amount differs considerably in the different stages of the disease ; being but 
small in quantity in the intense stage of collapse, increasing during reaction, 
and in excess when consecutive febrile symptoms occur. 

61. Analyses of the Blood in Cholera. — Dr. William Robertson read before the 
Medico-Chirurgical Society of Edinburgh (April 4) an account of his observa- 
tions on the blood drawn from patients labouring under cholera. He grouped 
the cases under four heads, described the appearance and general properties of 
the blood in each, and exhibited the general chemical results obtained from 
thirty analyses, conducted according to Andral and Gavarret's process. Five 
of the analyses were made by Dr. Douglas Maclagan, one by Dr. Christison, 
and the rest by Dr. Robertson. 



Average 


Constitution of '1000 parts of Cholera Blood. 






Fib- 
rine. 


Org. Ser- 
ous Solids. 


Inor. 
Do. 


Globules. 


Total 
Solids. 


Water. 


Sp. gr. of 
Serum. 


Sp. gr. of 
Blood. 


Early stage, 
Early collapse, 

i Collapse, 

j Reaction stage, 


2.7 
3.2 
3.2 
3.5 


82.2 

94.0 

101.2 

76.6 


7.8 
7.0 
6.9 
6.6 


103.4 
130.8 
130.0 
126.7 


196.1 
235.0 
241.3 
213.4 


803.9 

765.0 

758.7 
786.6 


1030.0 
1033.7 
1036.6 
1030.6 


1053.7 
1059.5 
1066.4 
1057.9 



Distinct indications of the presence of urea had been obtained both by Dr. D. 
Maclagan and by Dr. Robertson, upon testing blood taken from the heart and 
veins after death, and on one occasion Dr. Maclagan had obtained similar indi- 
cations, upon examining blood drawn from the arm during the early stage of 
the disease. Urea seemed most abundant in the blood of patients who died 
during the stage of reaction ; 1000 grains of blood yielding in one case 1.6, in 
another .73 of nitrate of urea. The chief conclusion which these analyses, cou- 
pled with certain phenomena of the disease, suggested, were, 1st — That anaemia, 
or an impoverished condition of the blood, acted as a predisposing cause of cho- 
lera. 2dly. That, although during cholera the relative proportion of the blood 
constituents was rapidly and singularly altered, there was yet no evidence that 
the primary operation of the morbific poison was exerted upon the circulating 
fluid, — the chemical changes recorded were only the effects of the morbid pro- 
cess. 3dly. That the changes which the blood underwent up to the period of 
reaction, consisted in a concentration of the serum from loss of water, and a loss 
of salts almost proportionate to the amount of water abstracted. 4thly. That 
the proportion of salts was lower during reaction or convalescence than dur- 
ing the progress of the disease. For every 1000 parts of water, there existed 
during the early stage 9.7, during early collapse 9.2, during collapse 9.1, and 
during reaction only 8.4 parts of mineral constituents of the serum. That, con- 
sequently, the phenomena of the stage of collapse could not be due to the loss 
of salts, and that the saline treatment did not rest upon a good theoretical 
foundation. 5thly. That the changes observed during reaction were probably 
due, in part, to absorption of fluid into the circulation, and consequent dilution 
of the blood. This absorption sufficiently accounted for the small per centage 
of inorganic serous solids during reaction, and might assist in explaining the 
marked diminution of the organic serous solids. 6thly. That during reaction 
the fibrine was often proportionately increased, and that there was reason to 
believe that blood corpuscles were at the same time rapidly formed. 7thly. 
That the albumen which was withdrawn from the circulation, was metamor- 
phosed, converted into tissues, excreted by the bowels, and in most cases like- 
wise excreted by the kidneys. In nearly eighty per cent, of the urines exam- 
ined during convalescence, albumen was detected; its absence might accord- 
ingly be regarded as exceptional. 8thly. That the formation and retention of 



1849.] Cholera. 257 

urea in the blood were always to be dreaded during reaction, and hence that the 
use of diuretic remedies, and especially of such as were believed to possess the 
property of expelling urea from the system, was clearly indicated. Tabular 
statements of the analyses were exhibited. 

Dr. Christison inquired whether an experiment which he had made during the 
former epidemic, and which proved that the dark blood of cholera was yet quite 
susceptible of arterialization, had been confirmed on this visit of the disease. 
He had found that the blood, when defibrinated by agitation in a phial with 
pieces of zinc, rapidly assumed the arterial hue when subsequently agitated 
with atmospheric air or with oxygen gas. Dr. Douglas Maclagan and Dr. 
William Eobertson had both recently confirmed the accuracy of Dr. Christi- 
son's observations. — Monthly Journal, May 1849. 

62. On the Liquids ejected in Cholera. By M. Mialhe. — M. Andral estab- 
lished, in a paper read to the Academy of Sciences in 1847, that, " The white 
fluid which fills the intestines of cholera patients is not actually a part of the 
blood, as has often been maintained, for neither albumen nor fibrine can be 
found in it ; but that it is formed by mucus, secreted suddenly and in large 
quantities, and by that very fact greatly altered in quality." By analyses made 
during the present epidemic, I find that the ejected fluid contains neither fibrine 
nor albumen, but yields, by certain chemical re-agents, a plentiful precipitate, 
which precipitate is albuminose. This latter substance is, as I have lately 
shown, the final product of the digestion of albuminous articles of food ; just as 
glucose is the final product of the digestion of amylaceous matters. Albumi- 
nose has characters in common with albumen : both are soluble in water and 
insoluble in alcohol, both give a precipitate by the addition of salts of lead, 
mercury, and silver ; oy chlorine and tannin. But albuminose, when isolated, 
does not coagulate by heat, nor acids, nor even by nitric acid. These two latter 
properties will at once distinguish albuminose from albumen. Now the cholera 
dejections coagulate neither by heat nor nitric acid, which fact points to the ab- 
sence of albumen : they give an abundant precipitate on the addition of alco- 
hol, the salts of lead ; mercury and silver, of chlorine, tannin, &c. ; which pre- 
cipitate is albuminose. The next question is, how this albuminose comes to be 
secreted by the economy ? Albuminose is not formed at once ; it can only take 
its origin in the albuminoid portions of the blood, and in the living tissues. 
The albuminous and fibrinous parts of the blood undergo, by the effects of 
cholera, a transformation analogous to that which would result from the di- 
gestion of these same principles in the stomach under the influence of pepsine. 
Muscles are liable to the same metamorphosis, and are thus exposed to a sort of 
interstitial absorption. The albuminose, thus formed, instead of ministering 
to the nutrition of the patient, as is the case in prolonged low diet, is, on the 
contrary, immediately driven from the system, both by the gastro-intestinal 
mucous membrane and the skin, to which latter it gives a very characteristic 
abnormal viscosity. The first albuminose secreted is furnished by the whole 
mass of the blood, and the muscles undergo their molecular transformation only 
secondarily ! This muscular absorption explains very satisfactorily the rapid 
phenomena of prostration and loss of flesh so remarkable in cholera patients. 
But if the albuminose arising from the blood found no difficulty in passing from 
the torrent of the circulation into the digestive cavities, it is far different with 
the albuminose which is derived from muscular interstitial absorption, for this 
second variety must, before oozing upon the surface of mucous membranes, 
pass through the capillary system, in order to enter the circulation. Hence, 
we shall have an arrest of circulation, and consequent upon it, cyanosis, algi- 
dity, and asphyxia, at the moment of the interstitial absorption, giving rise to 
considerable tumidity, (eight or ten times the original volume,) which the fibrin 
undergoes in order to dissolve and-be metamorphosed into albuminose. Such 
are the material causes which, according to my views, produce the hitherto un- 
explained phenomena of this dreadful disease. Thus it appears that the de- 
jections of cholera contain an enormous proportion of albuminose, and this 
albuminose can only be derived from the organic elements of the system. In 
searching for the cause of this extraordinary perturbation, one would be led to 



258 Progress of the Medical Sciences. [July 

admit a fermentiferous principle, which gives rise to phenomena entirely analo- 
gous to those of the digestion of albuminoid articles of food in the stomach. 
When the economy appropriates to itself the albuminous principles ingested 
into the body, it must subject them to a constitutive molecular decomposition, 
which effaces from them all traces of organization, The system then assimilates 
them, and gives them a new organization, which is the origin of albumen, 
fibrine, and cruor. Now it must be noticed, on the other hand, that these prin- 
ciples, thus newly formed, cannot leave the economy without having been com- 
pletely disorganized. This is exactly what takes place in cholera; a disease in 
which the presence of albuminose in the secretion is an evident proof of a disor- 
ganizing transformation. For, were it otherwise, we should see, not albuminose, 
but albumen, fibrine, and cruor escaping from the vessels, as by a kind of 
expression, through the intestinal mucous membrane, as most authors have 
hitherto believed. Starting from this hypothesis, it looks as if we could arrest 
or suspend the abnormal phenomena of cholera in the same way as certain fer- 
mentations are stopped. But all the substances calculated to produce this effect 
are unfortunately too active or poisonous ; as the salts of lead, copper, mercury, 
and silver, mineral acids, &c. They would, in fact, be more dangerous than 
the disease itself. Tannin (and all the medicines which act in virtue of this 
substance) would seem rather desirable, owing to its faint action on the mucous 
membrane ; but in spite of the favourable results obtained by Dr. Graff, of 
Berlin, it should not be forgotten that tannin, at the same time that it acts upon 
the fermentiferous substances, acts also on the albuminoid principles, and that 
its coagulating powers must, in large doses, be rather dangerous. It seems 
extremely probable, that the different prophylactic means which have been ex- 
tolled in cholera, some being violent excitants, as mustard, pepper, cajeput oil, 
naphtha, creasote, the sesquichloride of carbon, solutions of potassa, soda, am- 
monia, and their various salts ; others, sedative or anaesthetic agents, as opium 
and its preparations, Indian hemp, ether, and chloroform, act by producing in 
the economy, the first, a powerful reaction ; the others, a stupefaction, which 
does not allow of the morbid disorganization. I regret, after having investi- 
gated the nature and the causes of the choleric affection, to have no especial 
method of cure to bring forward. I may, perhaps, conclude by stating that 
every one of the above-mentioned means may become all-powerful in the hands 
of an enlightened practitioner. — JJ Union Me'dicale. 

63. PaiJiology and Therapeutics of Cholera. — "There are certain points/ 7 
says Dr. Gaerod, in his interesting paper on the Pathological Condition of the 
Blood in Cholera, " with regard to the pathology and therapeutics of the disease, 
which the consideration of the results of the chemical examination of the blood 
and other fluids naturally suggests to the mind. In the first place, it would ap- 
pear that the cholera poison, when introduced into the blood in sufficient quan- 
tities, causes an intense exosmotic action of the mucous membrane of the 
alimentary canal, at the same time destroying its endosmotic power. The 
blood, therefore, being deprived of a certain amount of water and salts, by the 
intestinal evacuations, and, not possessing the power of regaining these by 
absorption from the stomach, becomes altered in the manner we have seen, and 
ill suited for circulation in the extreme vessels ; thereby giving rise to sup- 
pression of the various excreting functions, by which in turn it is rendered im- 
pure. But a question now arises: Is this condition of blood essential, and cannot 
the stage of collapse be induced by the direct influence of the poison ? There 
are certain cases known by the name of ' Cholera Sicca/ which would seem 
to favour this latter view ; but from what I can ascertain, no analyses of blood 
have been made in such, and as far as my own experience goes, the amount of 
intestinal evacuations in any case is by no means an indication of the extent to 
which the blood has become altered. This is also well shown by the condition 
of the blood in severe bilious diarrhoea, in which its specific gravity appears to 
remain unaltered, the endosmotic or absorbing power probably remaining 
entire. Supposing this latter property entirely suspended, it would require 
but little amount of intestinal evacuation to cause this condition of blood ; the 
loss of water by the skin and lungs would alone soon produce it ; and that this 



1849.] Cholera. 259 

power is sometimes lost, will be seen in examining Case V. ("Worts), in which, 
although many gallons of water were taken into the stomach, the blood still 
continued to increasean specific gravity. 

" Assuming that such a condition of intestinal mucous membrane exists in 
cholera, it gives us but little hopes of effecting much by remedies administered 
by the mouth, during the collapse : and experience has shown us, that very 
little confidence can be placed in them. The saline drinks, recommended by 
Dr. Stevens, must here fail, as even water is unable to be absorbed. This led 
to the method of injection of saline fluids into the veins ; and certainly it ap- 
pears that, even in the most intense stage of collapse, patients may, for a time, 
be restored by their employment. Unfortunately, however, the improvement 
has, in most cases, proved but temporary ; but still enough has been seen to 
cause many to think that their use is strongly called for. Should they be ever 
again employed, I think that more attention should be paid both to the nature 
and quantity of the salts contained in the fluid than has hitherto been done ; 
and a solution should be employed whose composition resembles, as much as 
possible, the portion of the blood which has been lost. One would be apt to 
think that the blood could not bear with impunity a considerable quantity of 
carbonate of soda in place of the phosphate ; yet such a substitution, I believe, 
has generally been made. May not the use of improper fluids have been in 
part the cause of the truth of the remark quoted by Dr. Watson, in his Lectures 
on the Practice of Medicine, that, • However it might be with pigs and herrings, 
salting a patient in cholera was not always the same thing as curing him/ 

" Might not some agent be injected, which would tend to prevent the exosmotic 
action of the intestines ? Certain bodies, possessing such a power on mem- 
branes, have been found. When reaction takes place, and the watery portion 
of the blood becomes restored, it would then seem rational to employ drinks 
containing small quantities of the salts ; for it does not seem improbable that 
the saline deficiency, which must then occur, unless supplied, may tend to pre- 
vent the due action of the kidneys and other excreting organs. At this time, 
also, other remedies, as calomel, etc., should be given, with the intention of 
restoring the excretions." — London Journ. Med., May 1849. 

64. Cholera — Absence of the Precursory Diarrhoea — Treatment of the Dis- 
ease. — At a meeting of the Royal Medical and Chirurgical Society, (Feb. 27,) 
Mr. Streeter said that he "should like to direct attention to the fact of the 
very large number of cases of cholera which occur without premonitory diar- 
rhoea, and to the greater danger attending those cases; for I do not think 
that sufficient attention has been paid to those cases in which collapse has 
been ushered in without previous symptoms, and to those in which there is 
scarcely any vomiting and purging, and which, I believe, are universally fatal. 
There are a large number of cases in which the disease is ushered in without 
previous purging and vomiting. With reference to treatment, I think a dis- 
tinction should be made between cases of collapse originating directly from the 
poison, and those in which premonitory diarrhoea has existed for several days, 
as in those cases the collapse is due partly to the poison, and partly to the 
exhaustion from serous evacuations. After the most careful observation, I have 
come to the belief that there can be no recovery except where nature or art sets 
up the action of vomiting ; and, as to remedies, any attempt to check that pro- 
cess checks the mode which nature adopts to overcome the disease. We are 
constantly told, in reference to the progress of a patient, that all is well 'except 
the vomiting ;' but I believe that the only successful way to produce reaction 
is to encourage the vomiting, and sustain it at intervals, regulated by the 
powers of the patient. With respect to the agent for the production of this, it 
seems to me to matter little ; mustard and salt have been favourite remedies, 
and certainly the latter, from its known harmlessness, is worthy of adoption ; 
cold water, also, will in many instances succeed ; but there have been cases in 
which it will not keep it up, and then powerful stimuli must be employed." 

Dr. Balt remarked that the subject of the relation of the precursory diarrhoea 
to cholera is important. The question is, whether the diarrhoea is a part of the 
disease, and if so, whether we can cut it short. "As far as I have observed at 
Millbank Prison, the diarrhoea is of three classes: in the one, there are one or 



260 Progress of the Medical Sciences. [July 

two evacuations before collapse ; in the second, there is serious diarrhoea, rice 
water evacuations, and occasional vomiting. In both these cases, I think the 
diarrhoea is a part of the disease ; but it seems to me impossible to stop it by the 
ordinary remedies. Then there is the third kind, in which at first the evacua- 
tions have not the character of rice water, and there is no vomiting or cramp. 
This goes on for several days, and in the early stage may be checked. The 
choleraic diarrhoea subsequently ensues. It appears to me that the early diar- 
rhoea in such cases, of which I have seen several, is not a part of the disease, but 
predisposes to it ; but this class is not very frequent ; in the more frequent cases, 
the ordinary remedies fail in cure. As to treatment of the cholera itself, I have 
not met with any greater success than others, and I believe that no one will 
succeed till a specific be found for it. We are at greater disadvantage in cholera 
than in typhus fever, because the effects of the typhus poison are more under 
our control than those of the cholera poison. Strong stimulants, I think, are of 
little avail, and, generally, the less we do the better. Warmth is beneficial, but 
not a great degree of heat ; a very moderate degree of heat is certainly good. 
I should also recommend the administration of cold water, not for the purpose of 
producing vomiting, but to dilute the blood. I have found benefit from the use 
of chloroform, which acts as a palliative, by relieving pain, the cramps, and 
vomiting." 

Dr. Balt said, that he had used the injection of saline fluids into the veins 
in six cases, and the result was uniformly death. " In the first case, the effect 
of it was very encouraging; the patient previously appeared to me as if in his 
last gasp ; in a quarter of an hour, he breathed gently, seemed in a quiet sleep, 
and the colour in the cheek was natural. In no other case was the effect so 
marked: while in all there was a return to collapse. In two cases I employed 
large doses of calomel ; one man had five 10-grain doses and five scruple doses, 
and after death it was all found in his stomach, with the exception of a small por- 
tion in the duodenum. " 

Mr. Streeter believes that the experience in Great Britain in the former 
epidemic has settled the point, that the treatment by injections of salines into 
the veins should be abandoned. " I at one time hoped much from stimulating 
the skin by mustard cataplasms on the arms and over the abdomen; they 
reddened the skin, but produced no reaction, and this was tried in several 
cases. I found that, unless vomiting was produced, reaction did not occur; and 
this from an experience that extended over some hundreds of cases. It is, I 
think, important that we should treat cases of diarrhoea as if they would turn 
to cholera, and my prescription generally was : 1 gr. opium, 1 gr. acetate of 
lead, 1 gr. capsicum, 1 gr. calomel. With respect to large doses of calomel, I 
found no benefit arising from them. (I gave half a drachm in one instance.) 
I also saw phosphorus administered in two cases, and in one case a pill was 
found, as taken, in the stomach, and, in the other, in the appendix vermiformis." 

Mr. Busk, surgeon of the Dreadnought, stated that " out of forty cases that 
have come under my notice, about half have terminated fatally ; so that, while 
the cases have not been numerous, they have been very fatal, and have been 
generally confined to young men of muscular strength, and who had been in a 
condition to obtain sufficient wholesome food; the majority of them have been 
from colliers. In these cases, I have observed a considerable difference in the 
type of the disease between that now prevailing and in the previous epidemic. 
I refer to the greater proportional number who have not died in a state of 
collapse at the present time ; they have generally died in a state of oppression 
and coma, and almost invariably with suppression of the urinary secretion. Also, 
in the symptoms of the disease in the state of collapse there is considerable 
difference ; the cramps are not so severe, the coldness not so intense, and the 
facility with which heat is restored is much greater now than formerly. In 
many cases the temperature in the axilla was 96, and that under the tongue 78, 
showing that the blood in the lungs was cool and probably stagnating. Another 
difference is, the absence of perspiration, while, in 1832, the perspiration was 
enormous. The duration of the disease, also, was very much longer, from their 
not dying in a state of collapse. On the treatment, I can add nothing to the 
observations of Dr. Baly and others ; my opinion is, that we have no treatment, 



1849.] Cholera. 261 

heroic or otherwise, suited to control the disease: the only thing I am certain 
of is, that chloroform relieves the cramps, and thus has a beneficial influence in 
the way of relief ; but it has no other control over the disease. The chief force 
of the disease, at the present time, seems to fall on the kidneys ; no means have 
had the effect of inducing secretion of the urine ; turpentine epithems and fric- 
tions have alike been unsuccessful. Another point is that, after the urine has 
been suppressed, and when it is again passed, the first is invariably albumi- 
nous ; the tubuli are usually found crammed with epithelium, and the functions 
of the gland are thus obstructed. The great thing here is, to excite the action 
of the kidneys. "With regard to the pathology of the disease, I have nothing 
particular to offer. There is an affection, however, of the large intestine which 
I do not remember to have seen described. It usually occurs in the transverse 
arch of the colon, and consists at first of congestion of a patch of the mucous 
membrane, which, if the case is prolonged, seems to be followed by circum- 
scribed gangrene. In these cases, especially, it would appear that bloody 
motions are passed; but motions of this character are not limited to them. 
Blood, in any quantity, in the motions, has almost invariably been a fatal sign. 
(The speaker here exhibited two specimens, consisting of the transverse arch 
of the colon, showing the simple ecchymosis and gangrene of the mucous mem- 
brane.) No doubt it must be very violent action which produces this extreme 
disorganization ; the disease appears to depend upon the introduction of a mor- 
bid poison, which nature making an effort to eliminate, the attempt destroys 
the membrane. — Med. Times, March 10, 1849. 

65. Effect of Remedies in Cholera. — In a conversation at the Medico-Chirurgi- 
cal Society regarding the effects of remedies during the recent epidemic of cho- 
lera at Edinburgh, it was stated that the saline injection of the veins had been 
practiced in the cholera hospital in twenty-five or twenty-six cases, and that, 
although remarkable temporary benefit seemed sometimes to result, no patient 
had survived the operation more than eight days. In 1832, about l-6th of those 
whose veins were injected recovered; profound collapse was, however, not 
always waited for, before recourse was had to the operation. The diuretics used 
on the present occasion were bitart.-potass, nitre, digitalis, colchicum, and tinct. 
lyttae. Blood-letting, practiced early, was the remedy which Dr. Robertson had 
found most efficacious in averting the most formidable symptoms of the disease. 
— Monthly Journal, May 1849. 

66. Treatment of Asiatic Cholera by Internal and External Means. — M. Blatin 
stated to the French Academy of Medicine, Jan. 23d, at great length, the prin- 
cipal treatment which he was in the habit of adopting in the district where he 
practiced. He said that, out of 225 severe cases of cholera, he had only had 
44 deaths, although, out of 461 patients, equally affected with the disease, 
the mortality rose to 196. The internal treatment which he recommends, in the 
majority of cases, consists, almost exclusively, of the administration of cold 
water in large doses. We know the extreme thirst which torments cholera 
patients ; and we know the ardour with which they beg for cooling drinks. The 
observation of this fact induced M. Blatin, after some trials, not only to satisfy 
the desire of the patients, but to induce them to take quantities of liquid, which 
would appear enormous, were we to lose sight of the vomiting and purging. 
Some of his patients drunk between five and six pailfuls of cold water in the 
day. This remedy favoured the return of heat in a very manifest manner, and 
assisted in modifying the secretions, with regard to their sero-albuminous cha- 
racter, to such an extent that, at the commencement of the treatment, the 
patients drank with extreme avidity. With reference to bleeding, M. Blatin 
thus expressed himself: — "At the commencement of the disease, moderate 
bleeding does not appear to me to be injurious; it has appeared to me to pro- 
mote an improved state of the blood. During reaction, I have rarely ever found 
it necessary ; this is probably due to my having watched carefully the approach 
and progress of that state, and not having hastened it by a stimulating plan of 
treatment. Leeches, which I have frequently applied to the epigastrium, have 
suckod but little, and have sometimes died on the place ; and there has been no 
hemorrhage after their removal. During the algide period, I have found it 



262 Progress of the Medical Sciences. [July- 

useless to attempt bleeding from the arm, or by cupping-glasses. I have opened 
the temporal artery at least ten times, and usually, after from 100 to 150 
grammes (from 3£ to 5 oz. of English avoirdupois weight) of slightly red blood, 
the bleeding has ceased spontaneously. In three cases I observed some bubbles 
of gas escape with the first drops of liquid, from the opening which I made in 
the arm. The result in each of these cases was fatal. Is there a decomposition 
of fluid in cholera patients ? I am inclined to think that there is. ;; — Lond. 
Journ. Med., March 1849. 

67. Treatment of Cholera in six of the Parisian Hospitals. — The Gazette Medi- 
cate de Paris, of May 12th and 19th, contains the following account of the prac- 
tice adopted by the medical officers of six of the Parisian hospitals, in the 
treatment of cholera : 

I. Hotel-Dieu. The patients who enter this institution are of all ages and 
of both sexes, and mostly destitute. The hospital is generally supposed to be 
one of the most unhealthy, being situated on the Seine, badly ventilated, and 
over-crowded. The medical practice is based on anatomy and physiology, as 
may be easily imagined when we remember that Chomel, Louis, and Rostan 
teach and practice there. Their treatment is hence to a great extent uniform, 
and is of the following character : 

For diarrhoea, most employ opium and its preparations, and astringents ; and 
all reject emeto-cathartic remedies. To allay vomiting, they give ice, iced Seltzer 
water, and the anti-emetic potion of Riverius. Depression is treated by various 
internal and external stimulants ; pain, by calmatives, and in certain cases by 
revulsives ; the loss of warmth, by various calefacient remedies, one using the 
vapour bath, another the hot air bath, another the water bath, at a temperature 
of 40° to 42° cent. (104° to 107° Fahr.). Excessive heat, and the appearance 
of internal congestion, treated by local depletion, cold water, and even by ice. 
With the exception of that of two of the medical officers, one of whom trusts 
to saline treatment, and another to emetics, the treatment adopted in the H6tel- 
Dieu is of the above character, being neither specific, nor remarkably violent, 
nor purely empiric, but a system of physiological rationalism. 

M. Chomel admits the existence of several forms of cholera, each requiring 
its appropriate treatment. These are — the nervous form, characterized by the 
predominance of pain, cramps, and disturbance of the intestines ; the algide 
form, by diminution of heat, and disturbance of circulation and respiration ; 
the gastro- intestinal form, by the abundance of the evacuations ; and the inflam- 
matory form, bearing some resemblance to acute gastritis and dysentery. In 
the nervous form, M. Chomel administers opium by the mouth or in injections, 
or both ways at once, if possible ; if it cannot be administered in either of these 
ways, he employs the endermic method. In the algide stage, M. Chomel pre-, 
fers dry to moist vapour baths ; the latter favouring the retention on the sur- 
face of the cold clammy sweat which opposes reaction, and with diarrhoea and 
vomiting, tends to produce colliquation. When the hot air bath cannot be 
conveniently administered, he uses bags of hot sand, which have the advantage 
over bottles of hot water, of being capable of being equally adapted to all parts 
of the surface. For similar reasons, he prefers friction with aromatic sub- 
stances, benzoin, frankincense, or juniper berries. He sometimes employs 
friction with pounded ice, but only in cases where the algide symptoms are re- 
cent, and the patient young and of a strong constitution ; in patients of weak 
constitution, he entirely rejects this remedy. The internal remedies which he 
employs are hot tea punch, alcoholic drinks, etc. : but these do not seem to him 
suitable when the patient complains of internal heat; in such cases, he pre- 
scribes ice, with excitants. In the inflammatory form, with heat of skin, and 
full, resisting pulse, he employs general or local bleeding, cataplasms to the 
abdomen, baths, emollient and demulcent draughts, with opium. The anti- 
phlogistic treatment must always be regulated by the debility of the patient, 
and the prostration consequent on the attack. If vomiting be abundant and 
frequent, M. Chomel administers ice in small fragments, or pounded, in small 
quantities and at short intervals, so that it may be brought into contact with 
the stomach in a continuous manner. Seltzer water with ice, the anti-emetic 



1849.] Cholera. 263 

draught, subnitrate of bismuth, calumba, and opium, are alternately used, to 
fulfil the same indication. If the vomiting obstinately resist these means, he 
applies a blister to the epigastric region ; more rarely, and only when there are 
symptoms of gastric inflammation, he employs cupping or leeches. Diarrhoea 
is treated by moderation in the quantity of drink, opiate, or astringent injec- 
tions, with alum, rhatany, monesia, etc. ; and a large blister to the abdomen in 
obstinate cases. M. Chomel treats cramps by opium, used in frictions and in- 
ternally. He pays much attention to dyspnoea ; if it be accompanied with fe- 
brile reaction, he employs general bleeding ; but if — which is much more fre- 
quent — there be no fever, he treats it by diffusible stimulants, as ether, and 
nitrate of ammonia. In cases complicated at the commencement with cerebral 
symptoms, opium is excluded from the treatment, and revulsives are employed, 
as blisters on the limbs, and laxatives, if there be no diarrhoea. When debility 
is the prevailing symptom, the treatment consists chiefly of tonics. 

M. Louis. The treatment adopted by this physician does not differ sensibly 
from that of M. Chomel. Besides those remedies which may be called for by 
certain symptoms, his method of treatment mainly consists of calefacients, 
viz., the hot air bath and warm infusion of mint, to restore the heat and excite 
the circulation; and aromatic stimulants, with injections, containing ten or 
twelve drops of laudanum, several times daily, to restrain the evacuations and 
pains. When heat is re-established, Seltzer water is substituted for aromatic 
draughts. 

M. Kostan prefers, at the commencement of the disease, for the purpose of 
restoring heat, hot water baths, at a temperature of 40 to 42 cent., followed by 
some hot aromatic infusion, and friction of the limbs with ammonia liniment. 
If these means are insufficient, a mixture, containing ether, alcohol, and lau- 
danum, is administered. Acidity of the secretions is treated by alkaline reme- 
dies, as ammonia, or lime-water ; vomiting and diarrhoea by opium, adminis- 
tered by mouth, and in enemata, containing each six drops of laudanum. In 
reaction, moderate bleeding is sometimes employed, but only when there are 
symptoms of internal congestion. In obstinate vomiting, a large blister is ap- 
plied to the epigastric region. 

M. Husson's treatment, which differs little from the preceding, consists in the 
use of hot air baths, dry frictions, and the following stimulant mixture : In- 
fusion of limes or of mint, one hundred and twenty grammes ; acetate of ammo- 
nia, two to four grammes ; wine of Bagnols, sixty grammes ; tincture of 
canella, four grammes. He treats diarrhoea by opiate injections; obstinate 
vomiting, after reaction, by ice ; and administers quinine during convalescence. 

M. Martin Solon. The remedies employed in the practice of M. Martin 
Solon are partly adapted to particular symptoms, and partly intended to act in 
a special manner on the system and to modify the state of the blood. The 
treatment of individual symptoms comprises the use of the hot air bath on the 
admission of the patient, if in the algide stage, and the administration of one 
of the following mixtures : laudanum of Sydenham, twenty-five drops ; Hoff- 
mann's liquor, fifteen drops; infusion of mint, sixty grammes; ammonia, 
twenty drops ; syrup, thirty grammes ; or a mixture of distilled mint-water, 
ammonia, powdered calumba, and trisnitrate of bismuth : these mixtures are 
alternated with punch. For diarrhoea, he employs opiate and albuminous ene- 
mata ; and applies, immediately after the hot air bath has been used, sinapisms 
to the abdomen, chest, and vertebral column, to maintain warmth, or excite it, 
if the hot air bath have not been sufficient. To fulfil the second indication, he 
administers carbonate of ammonia, in doses of thirty centigrammes (about 4J 
grains), six times a-day. In obstinate vomiting, he uses cupping over the epi- 
gastrium, or a blister, which is afterwards dressed with a centigramme (about |- 
of a grain) of hydrochlorate of morphia. Diarrhoea is treated by injections, 
containing trisnitrate of bismuth ; and suppression of urine by a ptisan of 
couch grass and nitrate of potash. During convalescence, he gives wine of 
Bagnols with Seltzer water. 

M. Guerard distinguishes three principal stages of the disease. At the com- 
mencement, when there are diarrhoea and vomiting, without cyanosis or cramps, 
whether this be only cholerine, or incipient cholera, he uses narcotics, astringent 



264 Progress of the Medical Sciences. [July 

injections, and rice-water; and, if the prodromata continue in spite of these, 
opiate electuary and vinous drinks. When cholera has obviously declared it- 
self, he prescribes the hot air bath every quarter of an hour ; aromatic drinks ; 
ice and Seltzer water for vomiting ; lemonade, with wine, if it can be borne, to 
be continued also after the vomiting has ceased. To relieve the cramps, and 
other neuralgic symptoms, he gives ether and chloroform : the latter remedy 
has appeared to him well calculated to fulfil this indication. When moderate 
reaction has set in, he confines himself to the expectant treatment; if it be ex- 
cessive, with symptoms of internal congestion, he employs local and general 
bleedings, and sinapisms. If diarrhoea persist after reaction, he treats it by 
nitrate of silver, in mixtures, or in injections, containing about two and a half 
grains. 

M. Honore employed vapour baths ; hot aromatic draughts, with syrup and 
ether ; Seltzer water ; dry frictions ; enemata of rhatany and laudanum ; wine 
of Bagnols, with laudanum, in spoonfuls ; ice ; bleeding, Seltzer water, and 
lemonade, after reaction. 

M. Leger, who has succeeded M. Honore, adopts the saline treatment, recom- 
mended by Dr. Stevens. He gives common salt, in mixture and enemata; the 
daily dose of each being from fifteen to twenty-five grammes, until the vomiting 
has ceased. He states that the vomiting is generally increased at first, but 
soon diminishes, and usually ceases in about twelve hours. The effect on the 
alvine evacuations is still more rapid ; the first injections often restoring their 
natural bilious character. The only additional remedy which he employs in 
the early stage, is hot cloths, to restore warmth. 

M. Tardieu at first employed sea-water in five cases, in one only of which 
it appeared to produce permanently beneficial results. The restoration of the 
bilious character of the evacuations was the most obvious effect of this treat- 
ment. He now gives stimulants, preceded by an ipecacuanha emetic, hot air 
baths, aromatic infusions, Seltzer water, etc. He only uses opium where the 
cramps and other nervous symptoms are very intense, and is very guarded in 
its use, from the dread of cerebral complications. 

Hopital de la Charite. The situation and internal arrangements of this 
hospital are more healthy than those of the Hotel Dieu, and its inmates are 
mostly from a better class of the community. The medical treatment also pre- 
sents more diversity. 

M. Fouquier, and M. Oulmont. M. Oulmont was the first to introduce the 
saline treatment into the Parisian hospitals ; and he employs this method in 
all cases of cholera, admitting, as an aid, only the external means of restoring 
warmth. His prescriptions uniformly are: common salt, fifteen grammes; 
gum-mixture, one hundred and twenty grammes , to be taken every quarter of 
an hour in spoonfuls ; and two or three enemata during the day, containing fif- 
teen grammes of salt with a sufficient quantity of water. This treatment has 
not, as M. Oulmont himself confesses, entirely answered the expectations formed 
regarding it. M. Fouquier does not seem to have adopted any exclusive mode 
of treatment, but to have generally given emetics of ipecacuanha, in doses of 
two grammes, with diffusible stimulants, and opiate injections. 

M. Rater abstains from all experiments, and employs the same treatment as 
he adopted in 1832. He considers the digestive organs as the chief seat of the 
disease, and prescribes, in all cases, either ten centigrammes of opium in pills, 
during the day ; or a mixture, with from six to twelve drops of laudanum, and 
three or four injections, each containing twelve drops of laudanum; cupping to 
the epigastric or umbilical regions several days in succession, or even several 
times in the same day ; venesection from the arm, when possible ; iced Seltzer 
water for common drink. In several cases complicated with delirium he has 
opened the temporal artery, but without success. 

M. Cruveilhier employs a very active and various treatment. Most com- 
monly, he administers at first hot aromatic infusions with ether ; then a com- 
bination of astringents and narcotics, with some such mixture as the following : 
peppermint water, one hundred and twenty grammes ; extract of catechu, one 
gramme; laudanum, twenty drops. For diarrhoea, he employs enemata con, 
taining from fifteen to twenty drops of laudanum ; and if there be local abdo* 



1849.] Cholera. 265 

minal, or thoracic pains, he has recourse to repeated local bleedings, until the 
pains have ceased. A succession of sinapisms to the limbs, and friction with a 
stimulating liniment, complete in general his treatment of the algide stage. In 
some very severe cases, almost foudroyants, he administers every half hour a 
spoonful of the following mixture : laudanum, three grammes ; ammonia, five 
grammes ; ether, fifteen grammes. The treatment in the intervals consists of 
draughts of hot water, sweetened with gum syrup ; sinapisms to surround the 
limbs ; a large sinapism to the abdomen, and a blister to the chest or vertebral 
column. M. Cruveilhier has tried the stachys, but without any sensible result, 
which may be ascribed to his having combined it with opium and other reme- 
dies. 

M. Botjillaud generally adopts the saline treatment, and gives daily fifteen 
grammes of salt in mixture, and two enemata, each containing fifteen grammes 
of salt. The only additional means which he uses are ice and Seltzer water, 
and sinapisms to restore warmth. He rarely uses the hot air bath, and only 
when algidity is obstinate. More rarely, M. Bouillaud uses opiate enemata, 
with ice and Seltzer water, sinapisms and stimulating liniments. He is entirely 
opposed to general or local bleeding, even in the sjpge of reaction. 

M. Briquet. All the efforts of M. Briquet are directed to the promotion of 
reaction, at the same time that he employs opiates for the evacuations and 
pains. His treatment at first consisted of the hot air bath, infusion of mint, or 
punch, frictions with ammonia, and sinapisms to the limbs. He has since 
adopted a more active method, consisting of the alternate administration of ice 
and hot aromatic and stimulant drinks, and alternate frictions with pounded 
ice, and with alcoholic and ammoniacal liniments every half hour. The other 
indications are fulfilled by pills of thebaic extract, mixtures with acetate of 
morphia, enemata of starch and laudanum (six to twelve drops), Seltzer water, 
etc. In some cases he has given emetics of ipecacuanha, in doses of one or 
two grammes. The comparative result of his treatment is not known. 

M. Pidottx has not confined himself to any one method, but has employed a 
varied treatment. At first he prescribed, in the algide stage, diffusible stimu- 
lants with narcotics, as tea, hot infusions of lime, or mint, with syrup of ether 
and of opium, a succession of sinapisms to the limbs, etc. ; ice and Seltzer wa- 
ter, when reaction had commenced. More recently, he employed opium in 
large doses, in mixture and injections ; but was soon led to renounce its use, 
from its appearing to produce severe cerebral disturbance. Saline injections 
have also been tried and abandoned. M. Pidoux employed electro-galvanism in 
some cases with the effect of relieving some of the more distressing nervous 
symptoms, as cramp, hiccup, vomiting, etc. ; but he has not repeated this re- 
medy. He has also tried the terchloride of carbon, but without sensible effect. 

At present, he is making experiments on -the utility of trisnitrate of bismuth 
in diarrhoea. 

Hopital du Val-de-Grace. This being a military hospital, its inmates con- 
sist of men generally of good constitution, and not weakened by privations or 
excesses. It must be remembered, however, that the present dwellings of many 
of the soldiers in Paris do not present the most satisfactory conditions of aera- 
tion, dryness, and ventilation. The hospital itself is in a healthy situation, 
and its internal arrangements seem perfect. 

M. Levy, the chief physician, describes three periods in the progress of cho- 
lera ; two of which — those of prodromata, and of reaction — are amenable to 
a rational system of therapeutics, and the third — the organic or asphyxic — is 
treated as yet empirically, with more or less success. 

1. Prodromata. This period extends from the first disturbance of general 
health, to the appearance of cholera stools or spasmodic symptoms. There are 
three principal forms, each requiring appropriate treatment, a. Nervous form, 
indicated by headache, vertigo, weakness of the lower limbs, transitory epigas- 
tric spasms, transitory impediment to respiration, etc. Treatment: Repose, 
warm infusions, sudorifics ; and if these be insufficient, ipecacuanha in emetic 
doses, b. Saburral form, indicated by malaise, sense of weight at epigastrium, 
foul mouth, anorexia, lassitude, lumbar pains, and cephalalgia. The emetic 
treatment is successful here, even when> besides these symptoms, there are 



266 Progress of the Medical Sciences. [July 

some cramps and stools more or less typical of cholera. If there be also gar- 
gouillement, or ventral intumescence, the heat and pulse being normal, M. Levy 
employs laxatives, preceded or not by an emetic ; by these means he has ar- 
rested the course of some apparently severe cases, in spite of severe symptoms 
having occurred in addition to those of the premonitory stage, c. Diarrhoea! 
form, or cholerine : treated by opiates, especially enemata with laudanum, three 
or four times a day ; and ipecacuanha when these fail. 

2. Developed Cholera. This period has two distinguishing characteristics — 
tendency to cold and loss of pulse : but there are various other symptoms refer- 
able to the abdominal, thoracic, or cranio-spinal viscera, one or more of which 
may be present, giving rise to a variety in type and treatment. 

a. Cyanic and algide form, with thready or imperceptible pulse; or adynamic 
form. This is the form presented in many sudden attacks. There may or may 
not have been diarrhoea and vomiting, and the patients present rapid cyanosis, 
with general algidity, or confined to the face, tongue, and limbs : the skin is 
pasty, and moistened with a cold, clammy sweat ; there is extreme prostration, 
wrinkling of the face, hollowing of the orbits, etc. The patients make little or 
no complaint, but fall into a kind of coma which ends in death. In these cases, 
M. Levy has recourse to the energetic use of calefacients, by directing streams 
of hot air on different parts of the body, and administering hot infusions, and 
stimulating mixtures with acetate of ammonia. In the intervals, he gives hot 
coffee, or wine of canella. The ptisan which he prefers, is sweetened infusion 
of balm, with twenty or thirty drops of tincture of canella to the quart. 

b. Cyanic and algide form, loith predominance of gastro-intestinal symptoms 
[vomiting and diarrhoea). The same external means of restoring heat are em- 
ployed ; but internal stimulants and hot drinks generally increase the vomiting, 
or, at least, are soon rejected. The internal remedies are, ice in fragments, 
effervescing lemonade ; and the only stimulant which the patients seem able 
and willing to bear, is coffee. In almost all, who have been much exhausted 
by vomiting, there is severe pain in the epigastric region, and general abdomi- 
nal tenderness ; obstinate hiccup also supervenes. In these cases, M. Levy 
employs, in addition to ice and lemonade, the repeated application of sinapisms 
to the epigastrium, cupping and dry-cupping, followed by laudanized poultices ; 
if these means fail, he applies a small ammonia blister to the epigastrium, and 
dresses it with increasing doses of morphia. It may be remarked, in passing, 
that the blistered surface rapidly heals, and leaves a brownish scar, with thick- 
ening of the skin, due to the sanguineous infiltration of the part. In more 
obstinate cases, trisnitrate of bismuth, in doses of one gramme every hour, up 
to ten or twelve grammes, has been found successful ; it seems first to increase 
the intervals of, then to suppress, the vomiting. Its action is manifest, if at 
all, when from four to six grammes have been taken. Diarrhoea and vomiting 
have been less obstinate in the patients in the Hopital de Val-de-Gr&ce than 
elsewhere. The use of astringents does not seem to M. Levy to be useful or 
beneficial ; but he thinks that these symptoms are to be remedied by treating 
the general state of the system. 

c. Cyanic and algide form, with predominance of nervous and spasmodic symp- 
toms. This is an important form, and most difficult to treat. The patients, — 
cold, icy, blue, or only of a bistre-tint, pulseless, tortured by cramps, breath- 
less and anxious, from constriction of the thorax, which appears due, as well 
as the wrinkled countenance and sunken eyes, to muscular retraction, and who 
are a prey to jactitation, anguish, and severe pains, — form the greatest number 
of victims. Though ice-cold, they throw off the bed-clothes f they complain of 
insupportable heat ; the hot air bath becomes a punishment to them, and in- 
creases the oppression and anxiety. M. Levy substitutes for this, jars of hot 
water, long-continued frictions, which at the same time relieve the cramps, 
hand-sinapisms, moved up and down the limbs, and the internal use of hot 
drinks. This is, without exception, the most severe form of the disease, and 
that in which several new remedies have been unsuccessfully employed ; viz : 
electricity (by Dujardin's apparatus), ipecacuanha, in doses of from two to four 
grammes, hachisch, extract of nux vomica, and strychnine. M. Levy employs 
here the same treatment as he did at the commencement of the epidemic, with 



1849.] Cholera. 267 

the exception of the hot air bath. Externally, he employs frictions of lauda- 
num with turpentine, camphorated oil with laudanum, baume tranquille with 
chloroform, etc. For internal use, he depends more on ether and laudanum 
than on acetate o:f> ammonia. 

3. Reaction. Clinical observations and post-mortem examinations have fur- 
nished M. Levy with the key to the treatment of this stage. The forms and 
complications of reaction are in close relation with the anatomical conditions 
of the asphyxic stage ; and the attentive study of the peculiarities presented by 
the latter will almost enable one to foretell and calculate on the local tenden- 
cies of the former. The cyanic, or algide stage, tends to produce congestions, 
sanguineous extravasations, ecchymoses, etc. ; and when reaction takes place, 
the organs which are the seat of these lesions, become subject to hypersthenia, 
excitement, or phlogosis ; inflammation even often becomes one of the condi- 
tions of recovery. When the organs have been uniformly and moderately con- 
gested, and the reaction is gradual and continuous, there is a slight elevation 
of pulse, with general perspiration, and turbid or increased urine ; here the ex- 
pectant treatment is sufficient. Sometimes the reaction is more violent, but 
still general; and a kind of inflammatory fever arises, which only requires hy- 
gienic treatment and careful watching. But in a great number of cases, con- 
gestive symptoms have been confined to the brain, the lungs, or the intestinal 
canal. Under the first head, are classed secondary encephalic congestions, ob- 
stinate headaches, with or without fever, torpidity, most frequently accompa- 
nied by vomiting, as in hydrocephalus after cerebro-spinal meningitis ; the state 
of drowsiness and coma which succeeds this ; delirium, sometimes furious, some- 
times muttering, with intervals of slumber ; being in proportion to the degree 
of injection of the meninges, and of sub-arachnoidean and ventricular effusion. 
According to the degree of compression of the brain by the distension of the 
vessels of the periphery, and to the degree of febrile excitement, there are ob- 
served the symptoms of meningitis, of typhoid fever, of meningo-cephalitis ; 
and the most frequent is the torpid state, with vomiting and constipation. Ac- 
cording to the nature of the case, M. Levy adopts the semi-recumbent posture, 
depletion at the base of the skull, derivatives to the digestive canal (Seidlitz 
water, sulphate of soda, laxative enemata), and revulsives (sinapisms and blis- 
ters) to the extremities, and sometimes a blister to the nape of the neck; and in 
a number of cases, his treatment has been successful. Several cases of reac- 
tional pneumonia have been cured by bleeding to about eight ounces, opiate 
emetics, and blisters. The various abdominal inflammatory complications yield 
readily to cupping, laudanized poultices, and hygienic means. Severe and per- 
sistent pain in the epigastric region has been relieved by the application of 
ten or twelve leeches. Constipation is, more frequently than diarrhoea, accom- 
panied with ventral irritation, and must be treated by enemata and by means 
of regimen. Diarrhoea is the ordinary symptom of relapse, and should be care- 
fully sought for, especially as its existence is often concealed by the patients. 

Hopital de la Pitie. The situation and internal arrangements of this hos- 
pital are healthy: but its patients are mostly of the lowest class, from a popu- 
lation decimated by misery, badly lodged and clothed, and ruined by every 
kind of excess. The modes of treatment, though not completely opposed, pre- 
sent great differences. 

M. Serres considers cholera as a pernicious typhoid affection. The object 
of his treatment is to resolve the disease into its two principal elements, to 
master at first the pernicious phenomena, so as only to have subsequently to 
treat the typhoid fever, deprived of the complication to which it owes its seve- 
rity. One series of remedies is directed against the vomiting, the alvine evacua- 
tions, and the pernicious symptoms of the first period of the disease; another 
against the characteristic changes of the second, or typhoid period. The first 
indication is fulfilled by the anti-emetic potion of Riverius, Seltzer water, and 
citric lemonade, and starch enemata three or four times a day, containing cam- 
phor three grains ; sulphate of quinine three grains ; and laudanum eight 
drops. The specific treatment consists of daily mercurial inunctions to the 
abdomen, sometimes repeated several times a day, to the amount of eight or 
ten grammes of mercurial ointment ; and of the administration of the follow- 



268 Progress of the Medical Sciences. [July 

ing pills : iEthiops mineral one gramme ; powder of tragacanth half a gramme ; 
to be made into four pills with syrup, and taken during the day. In addition, 
he uses the ordinary means of restoring heat. Opium he employs with mode- 
ration, and only in enemata, except in some very rare cases, with painful cramps, 
where he gives a small dose of opium, with black sulphuret of mercury. He 
also rarely gives ether in mixtures. The comatose phenomena of reaction are 
treated with sinapisms, and sometimes, when very intense, by leeches behind 
the ears, and laxatives. 

M. Piorry. According to M. Piorry, the cause of cholera is a poison sui ge- 
neris, the effects of which are varied by the influence of septic agents. The 
intrinsic cause of cholera cannot be remedied, but we may greatly modify the 
conditions of septicity which give the disease its most severe character. His 
treatment of the intrinsic cause is mainly prophylactic, by withdrawing healthy 
individuals from the epidemic influence, or removing those who labour under 
the premonitory symptoms from their confined and ill-ventilated habitations. 
The disease, once developed, exercises its influence at first on the blood, then 
on the digestive canal. The action on the blood he treats by demulcent drinks, 
exposure to pure air, and copious water lavements. The gastro-intestinal symp- 
toms are treated by large quantities of infusions, especially tea, as long as vo- 
miting continues, and by albuminous drinks (whites of eggs beaten up in 
water), to remedy the incessant loss of albumen. M. Piorry does not employ 
evacuants, even though they seem indicated ; as he thinks them calculated to 
increase the debility of the patient to a dangerous extent. If the gastro-intes- 
tinal evacuations be obstinate, he applies bladders of ice to the whole of the 
abdomen, and hot cloths at the same time to the chest, and accompanies these 
with enemata of iced water. In the algide stage, he uses the vapour bath, tea, 
with alcoholic spirit, and copious injections of water. The indication here, ac- 
cording to M. Piorry, in this stage, as well as in the preceding, is to throw as 
much water as possible into the blood. For the phenomena of reaction, he 
has no fixed treatment ; but varies it according to the pathological conditions 
of the organs, as they manifest themselves. 

M. Gendrin considers that the disease consists of five principal orders of 
phenomena, which are successively developed ; viz., the premonitory symp- 
toms, which, according to him, are constant; the symptoms of excessive secre- 
tion, at the commencement of confirmed cholera ; the inspissation of the blood 
by the loss of its liquid constituents ; the suppression of all the secretions ; and, 
finally, febrile reaction in various forms. The indications founded on these 
five orders rest: 1. In the character of the precursory symptoms: which are 
most commonly diarrhoeal, much more rarely nervous or vertiginous ; 2. In the 
state of gastro-intestinal excessive secretion, which must be arrested; 3. In the 
changes which this secretion produces in the blood, which must be modified so 
as to maintain or re-establish a healthy circulation ; 4. In the febrile complica- 
tions of reaction, which must be moderated; 5. In the consecutive congestive 
phenomena, which are to be prevented. In the diarrhoeal form of the precur- 
sory symptoms, M. Gendrin prescribes emeto-cathartics, as ipecacuanha, fol- 
lowed by a saline purgative, with the object of modifying the excessive intes- 
tinal secretion. If the precursory symptoms consist in vertigo, headache, ge- 
neral courbature* without diarrhoea or vomiting, he prescribes a bleeding, ab- 
stinence from food, or a very moderate diet, demulcents, and a small dose of 
opium. In both cases he orders rest in bed, to favour the action of the skin, 
and to keep the body comfortably warm. In confirmed cholera, the first indi- 
cation is to moderate the state of secretory turgescence of the muciparous 
crypts of the intestinal mucous membrane ; to fulfil this, he employs bleedings 
at the commencement. If the disease have some intensity, he prescribes, in 
addition, opium in large doses, in solution or in tincture. If the evacuations 
have been sufficiently copious to produce symptoms of cyanosis, he has recourse 
to stimulating liniments, with the object of restoring the circulation, and of 
rousing the sensibility and the exhalant function of the cutaneous surface. If, 

* There is no English substantive by which the French word " courbature' 1 can be 
adequately translated. " Je me sens tout courbatu^ means, " I feel sore all over." 






1849.] Cholera. 269 

in spite of these means, the algide stage sets in, M. Gendrin employs vapour 
or hot-air baths only where the skin appears capable of reacting and perspiring. 
In the pronounced algide period, he continues the opiates, if the alvine secre- 
tions be still abundant: but considers that it is of most consequence to use 
tonic or simple stimulants, but not alcohol. In this period, he also depends 
greatly on external stimulants, as frictions, sinapisms, and blisters. With the 
object of giving play to the circulation, he prescribes bleeding; but as the veins 
allow only a small quantity of blood to escape, he leaves the vein open, and 
employs friction in the direction of the returning current of blood, until he 
has obtained some spoonfuls of blood. In the stage of reaction, the treatment 
of M. Gendrin differs, according as it is more or less complete and energetic. 
If it be incomplete, and the patient be much debilitated, and if the secretions, 
especially that of urine, be not re-established, he continues the use of internal 
and external stimulants, with the addition of sinapisms ; if, on the contrary, 
reaction be energetic, and coma be threatened, a small bleeding is practiced ; 
if it be well established and moderate, he confines himself to the expectant 
treatment. The obstinate vomiting, extreme thirst, and hiccup, so frequent in 
this period, are treated by ice. 

MM. Clement and Piedagnel generally employ the symptomatic method of 
treatment, with some modifications at the stages of commencement and reac- 
tion. At the commencement of the disease, M. Clement employs, in addition 
to astringents and opiates, leeching to the fundament. In the algide period, he 
uses stimulants with caution, for fear of exciting a too energetic reaction. In 
the precursory diarrhoea or cholerine, M. Clement would give ipecacuanha, but 
has not yet had an opportunity. The method of M. Piedagnel resembles that 
of M. Clement, except that he prefers a small bleeding to leeches to the anus. 
The characteristic feature of his treatment is, the employment of copious bleed- 
ings as soon as reaction sets in, so as to combat or prevent symptoms of cere- 
bral congestion. 

H6pital Saint-Louis. This hospital is situated in a populous quarter, and 
its structure is generally salubrious ; but the patients are generally in a bad 
hygienic condition ; hence the cases of cholera are numerous and severe. 

M. Gibert employs, almost exclusively, the rational or natural method, which 
consists in fulfilling such indications as present themselves, and in following 
the course which nature points out in effecting a spontaneous cure. During 
the precursory period of diarrhoea, he employs rest, dietetic treatment, demul- 
cent drinks, and opiate enemata. > In the algide period, he uses hot aromatic 
drinks at first, followed by gum water with Seltzer water and ice, poultices with 
laudanum, narcotic enemata ; and, at the same time, sinapisms, hot cloths, and 
frictions with laudanum over the regions troubled with cramp, so as to excite 
the circulation in the periphery, and to arrest the evacuations. In the stage of 
reaction, he applies cupping glasses to the chest and epigastrium, if there be 
ever so little dyspnoea, or tendency to asphyxia or coma. He does not employ 
bleeding, emetics, purgatives, nor specifics of any kind ; and even abstains from 
the use of hot air or vapour baths, which seem to him as much contraindicated 
as in asphyxia from drowning. Cases of cholerine are treated in the same way, 
and, according to M. Gibert, with uniform success. 

M. Devergie. The treatment adopted by M. Devergie does not entirely con- 
sist, as some imagine, in the use of truffles. He appears to treat each symptom 
by its appropriate remedies ; cold, for instance, by the hot air bath and internal 
stimulants ; vomiting, by ice and Seltzer water ; alvine evacuations, by opiate 
enemata. In some cases he has tried blistering of the epigastrium, by means 
of the long-continued application of tar ointment. 

A short time after the first appearance of cholera in Paris, M. Devergie, ob- 
serving that persons who eat truffles arc generally constipated, conceived the 
idea of employing them in the diarrhoea of cholera. He employed at first a 
simple decoction, made by boiling one hundred and twenty-five grammes (about 
four and a half ounces) of truffles, cut in small slices, with five quarts of water. 

This forms a ptisan which, when strained, is colourless and slightly opaline ; 
it has no disagreeable odour; and, when sweetened, has an agreeable taste to 
the patients. More recently, he has formed a distilled water from them, which 
No. XXXV.— July, 1849. 18 



270 Progress of the Medical Sciences. P^ly 

is charged with the odour of the truffles. By pounding the truffles in a mortar, 
and treating them with alcohol, he has formed a homogeneous mass, from 
which he proposed to form pills, by mixing a little sugar with the mass, and 
afterwards enveloping them in a layer of gelatine. Both in cholerine and in 
actual cholera, M. Devergie employed truffles as a remedy for vomiting and 
diarrhoea ; and says that some cases seem to have suddenly recovered on the 
cessation of the diarrhoea and vomiting. He has, however, completely aban- 
doned this remedy, which failed to answer his expectations. 

M. Moissenet employs the saline treatment, by chloride of sodium, to which 
we have already referred, as employed at the H6tel-Dieu and La Charite. In 
addition, he gives a ptisan of bicarbonate of soda, two grammes to the pint. 

H6pital Beaujon. This hospital is one of the most salubrious, but its 'in- 
mates are mostly from the villages about Paris, so that the hygienic conditions 
of the hospital are frequently counterbalanced by misery and insufficient food. 

M. Bouvier's mode of treatment is as follows. 1. To moderate the evacua- 
tions by means proportioned to their intensity, and to the exhaustion which 
they produce ; thus, by mouth, syrup of quinces in rice-water, at the com- 
mencement ; by the rectum, enemata of decoction of marshmallows, poppies, 
or of starch, with some drops of laudanum. Against vomiting, he uses Seltzer 
water, the potion of Rivierus, opium in small, repeated doses, ice, sinapisms to 
the epigastrium, and a small quantity of such drink as may be agreeable to the 
patient. Slices of orange or citron are applied to the lips and tongue to allay 
thirst, if all drinks, and even ice, be rejected. Cold water is given in small 
quantities, if the patients prefer it. 2. To sustain the power of the system 
and produce derivation from the intestines to the skin, he employs light tonic 
drinks, stimulants, external revulsives, cutaneous irritants ; infusion of tea 
with some spoonfuls of rum, coffee, wine of Bagnols with water, punch ; 
sinapisms, external heat, frictions with liniment of ammonia and cantharides. 
Stimulants, if too powerful, exhaust the rest of the system by producing too 
much cerebral irritation ; and should be employed with caution. 3. To prevent 
and combat cerebral congestion in the stage of reaction, M. Bouvier prefers cu- 
taneous revulsives, sinapisms, blisters to the nape of the neck and thighs, with 
support of the powers, to bleedings. He also adds antispasmodics, and opium 
if there be delirium or cerebral excitement ; and leeches sometimes, but only 
when specially indicated. 

M. Legroux. The treatment of cholera pursued by M. Legroux is the fol- 
lowing: 1. To restore warmth, and reanimate the patient, he employs hot 
cloths, in preference to bottles of hot water, which appear to him more hurtful 
than useful. At the same time, he gives hot drinks of tea with a little rum, 
etc. ; often also with a little syrup of ipecacuanha. These means generally 
produce prompt reaction. 2. When reaction is established, he gives cold iced 
drinks, which the patients take with eagerness. 3. At the same time, he gives 
a mixture with a small proportion of opium, to be taken by spoonfuls, and fol- 
lowed immediately by pills of tannin, to calm the nervous symptoms and di- 
minish the intestinal excretions ; also enemata containing laudanum and tan- 
nin, several times in the day. 4. When the patient has a certain amount of 
strength of pulse, he often practices bleeding at the commencement, which he 
does not hesitate to repeat if there be febrile reaction, especially when there is 
coma. The blood which flows is generally glutinous : local bleedings by cup- 
ping or leeches are often employed by him in cerebral complications, as well as 
blisters to the lower limbs. 5. In some cases, where the dull intestinal sound 
indicates their being filled with the cholera matters, he has employed, with ad- 
vantage, castor oil, alone, or with calomel. 6. Having observed in some cases 
a sort of alternate remission and exacerbation, he adds sulphate of quinine to 
the opiate enemata. 7. In cases of obstinate vomiting, he applies a blister to 
the pit of the stomach. 8. Obstinate diarrhoea is treated by enemata contain- 
ing a solution of nitrate of silver. 9. As to most of the remedies whose suc- 
cess has been declared wonderful, he has almost abandoned them, convinced 
that the modifications introduced into the system by cholera can by no means 
be cured by a single specific. 



1849.] Cholera. 271 

Hopital de Gros-Caillou. The general conditions of this hospital much 
resemble those of the Hopital de Val-de-Grace. 

M. Durand, at the commencement of the epidemic, employed hot air baths, 
stimulating aromatic infusions with acetate of ammonia, sulphuric ether, and 
laudanum, stimulating frictions, sinapisms, etc. When reaction had com- 
menced, ipecacuanha in fractional doses, with opium ; and when it was esta- 
blished, purgatives by mouth and in enemata, and sanguineous depletion when 
the congestive symptoms were very intense. But, having perceived that the 
most severe cases were those unattended with vomiting, and that the adminis- 
tration of stimulants tended to put off the excitement of vomiting, by reason 
of the increasing inertia of the stomach ; and also having observed that laxa- 
tives, given too soon after the algide stage, as well as the cold drinks to promote 
their action, tended to maintain the algide state, he has modified his treatment, 
so far as it relates to this stag